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Waste Tire S*ee& Inspection Repor ! I action Report Number <br /> State of California <br /> CIWMB 181 04104) <br /> I 1 11413 2 7 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_- --- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I !"� - O Inspection Type (Fill one) <br /> Site Suffix: V Q Routine O Re-inspection O Referral Q Observation <br /> Local Ski a�, �; n C�u�} If Referral,choose referral type(Fill one) <br /> Identifier: (' O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> C . �ru�'`�', enc_ 3 - <br /> Physical ddress <br /> \ Inspection Date I 0 <br /> oc *jo� C A ��05 Time In Time Out 1 <br /> Business Rep Title � O AM S O AM <br /> ►• �l� �O 1"W0� - I * PM ---� J 0 PM <br /> - - - - -- - -- - -- Operational Sire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 4D Passenger ® Generator Outdoor <br /> O Closed Q Altered <br /> GPS Latitude O Hauler Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned ® OTR O End-Use Q Container <br /> - - <br /> Business Type (Fill all that apply) ,1 <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture _Q Shredder I] Other <br /> p ........,. Y <br /> Part B- Ins Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT'STATUS <br /> V A°THAULING AND MANIFEST REQUIREMENTS-',:: <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance No Violations <br /> O 1 O Other: § <br /> Comments ��(,� Q 0L101 -� d <br /> �ror'T�l,�(� Stry I Ge- <br /> Inspection Form Included: O <br /> Comments Included: PJ� -- 200_?��S - � 773 <br /> 11 <br /> Business Rep's Signature Phone Number %pe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK rtS p � ��� 62081 <br /> White Copy:CW M Yellow Copy:Operator Pink Copy:LEA <br />