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® tL--i <br /> Waste Tire Su y & Inspection Report Inspection Report Number <br /> 411, <br /> 11i3-- State of CaliforniaC,WMB 181(New 04/04� <br /> California Integrated Waste Management Board Survey Form - Page 1 1 1 - 1006665 <br /> Part A- Survey BLUE OR BLACK-INK PEN <br /> Business Profile Inspection Details <br /> TPID- .-1 Inspection Type (Fill one) <br /> Site Suffix: t_ 14 4 l ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> , tDLOL O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> t-'(--'Lt.V� _ <br /> Phy ical Address <br /> r Inspection Date v / L C-> / t5 <br /> Time In Time Out <br /> Business Rep Title 0 AM <br /> � _ DAM <br /> 0 PM y 46 PM <br /> �u Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> © (a Active ® Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude — O Planned Q OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> S <br /> Q Notice Of Violatio Exten <br /> MANIFEST REQUIREMENTS <br /> - slon <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> m / m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i Referred 1 G,IW, B ( nfoncem..nt <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ; <br /> Compliance - No Violation <br /> Q Q Other: § <br /> Comments \ .� � v' <br /> tyrro of <br /> CXJVVJ'� <br /> Inspection Form Included: Q g 4 <br /> Comments Included: � �D <br /> iness Rep's Signature Phone Number Ins ector's Signature Phone Number <br /> INSTRUCTIONS ON BACKo p 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />