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Inspection Report Number <br /> Waste Tire Sulky & Inspection Repor� <br /> .m State of Californiaclw ® �p �y �y p p <br /> Califomi�a Integral d181(New 04104) <br /> )ment Board Survey Form - Page 1 Il -BB... �J9' 8 '/•91" 'i71 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> / i� ----- <br />} TPID- D <br /> � P � f �' LoLl , <br /> Inspection Type (Fill one) <br /> Site Suffix: '`�`'` ' t�1 fl 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local O / �—— — If Referral,choose referral type(Fill one) <br /> Identifier: ' ' Tv 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ( _ Inspected By Inspector <br /> i"1 ( t t "t til i aTPhysical Address L <br /> StrP,G't -' Inspection <br /> ° Ins ection Date <br /> Tr(+ t t �_�'� t � � �. Time In . <br /> � l � � Time Out <br /> City y mm -- 1 State ZIPt.,ocie) <br /> T11'] <br /> Business Rep Title J..0 '1AM <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> .7t) @ Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> jLQ Inactive 0 Truck <br /> O <br /> Longitude - 0 Planned 0 OTR O 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 r 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 <br /> M / M / m <br /> 0 i 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/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 0 In Compliance - No Violations <br /> O O !Other: § — -- <br /> CommentsTAJ1/Ido v I rr"F'tt � + J , rv� 1/i <br /> r'"T <br /> Inspection Form <br /> Included: 0! <br /> Comments Included: 0: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � A Mj P,L_�r , ' s,1 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> L <br />