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r<<„ Waste Tire St . _ley & Inspection Reports Inspection Report Number <br /> State B CaliforniaCIWMIl 1127497 <br /> California Integrated Waste181 eManagementBoard Survey Form w 04/04) - Page 1 <br /> Part A-Survey_ _. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I,� '^ O C' - O Inspection Type (Fill one) <br /> V <br /> Site Suffix: 0 `6 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(,�(1 �� LLj n WkaA�j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ` Inspected By Inspector <br /> -A e.mC S e w d- Sung 3 5 - l 0 � &0 �GsCn <br /> Physical Address J <br /> cA 9 s�S Inspection Date <br /> 11'L,JJ4� Time In Time Out <br /> Business Rep Title O AM u O AM <br /> 11 nn I,, v (a PM 1 O PM <br /> — - -- - -- - --- 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 /> Active Q Passenger If Generator ® Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> �g +e. Aga SwW <br /> Q Service Station Q Hauler Q Agriculture Q Shredder w(\rwj <br /> Other 5a S f�q.jr <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E>M <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1 11 'f 1)� . l <br /> 7 <br /> 51Z o9 , <br /> Inspection Form Included: Q 9Qg6739 v <br /> Comments Included: Q - - —-— - ---- - - - - --- <br /> �G�-31�� <br /> B slness Rep's Si nature Phone Number Inspec is Signature hone Number <br /> INSTRUCTIONS ON BACK Corr t ncorrect: "� : A M p 3 62081 <br /> White Copy: I Yellow Copy:Operator Pink Copy:LEA <br />