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ns ection Report Number, <br /> ® 4: Waste TState of ire S� -�/ & Inspection Repor�+°° p p _ <br /> Ar II <br /> CWMB 1(New04/04) urvey Form - Page 1 - 1108413 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN, <br /> - <br /> (Business Profile <br /> --- <br /> inspection Details <br /> TPID- 1 t J ) Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation, <br /> j <br /> Local ( �f — t If Referral,choose referral type(Fill one) <br /> Identifier <br /> ' i i 64 _ f •(.N", (L`; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> t t.{.1�._. — ---.. <br /> Business or FacilityName 1 _-- - <br /> Inspected By Inspector <br /> Ph T . v <br /> Physical Address <br /> y <br /> -� <br /> Street <br /> Inspection Date <br /> r V <br /> t r � State ZIP fade Time In Time Out <br /> Business Rep Title ` 0 AM 0 AM <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> r 7 n (Fill one only) (Fill all that ap (Fill all that apply) (Fill all that apply) <br /> lhl <br /> .Fire &;natant � h>�le/PTEA s � ,�S � �..�� 4• <br /> ® Active 0 Passeng a Generator 0 Outdoor <br /> G PS Latitude <br /> O 0 Closed 0 Altered 7 , <br /> • ,. �� Hauler Indoor <br /> - 0 0 Inactive (> Truck <br /> Longitude - — ^' 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / LE / El <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 (Other: § — ---,—. ---_. -�_- - -- <br /> Comments <br /> 4 ro! rr <br /> d (; 1 f r� ` _i%'.t �'(�t,, r t�:_`.{c�✓�")-('� ! <br /> it a(- <br /> ( } <br /> Inspection Form Included: 0 <br /> Comments included 01 <br /> ''Business Rep's Signature Phone Number Inspector's Signature <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />