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Waste Tire S410by & Inspection Rep" Inspection Report Number ■ <br /> kAClWMBState of California <br /> I1 - 1143806 <br /> 181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey— _-- _ _- -- _ <br /> Business Profile Inspection Details <br /> TPID- 4 c, Inspection Type (Fill one) <br /> Site Suffix: ?j -73 0 �Q V I (ARoutine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S A n J It; f) co Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> FaimS 3 G� — ' 0 <br /> Physical Addres <br /> ^ n Inspection Date <br /> SAD(J�J"�_ � CA qs-os Time In Time Out <br /> Business Rep Title * AM � AM <br /> 1 t ' I � O O PM � [7 PM <br /> L 0 rc-n 1ALASC1,\ �Q,f,�ant C, - - - —-- — - - - <br /> --- - -—-- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) j 1' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I *Active a Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned If OTR <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 /> Q Service Station Q Hauler Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility r ENFORCEMENT STATUS <br /> V q HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / 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 EXT) <br /> Q O -- - <br /> 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/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 S In Compliance - No Violations <br /> Q Q Other: § <br /> Comments O `er 1 _� j r1 door A onl S_ s.-a 11 rte'• <br /> 61-e-V`16lAM-v-s_11 ods c�Ytu,���^ "- _(,17n(�-� r1 - <br /> VU.Ci�1� 1 1�� Le��1tl&I V'S s"I'CAJ Wi�Sflr\ <br /> Inspection Form Included: Q f� <br /> y <br /> Comments Included: Q v` - 4hqon�eqNumberBusiness Rep's Signa re Phone Number Inspect ignature&a6 <br /> __ - - <br /> - <br /> - - ��,�' 62081 <br /> INSTRUCTIONS ON BACK � Correct 0 Incorrect. � V l[E_ <br /> E ?C 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :LE <br /> ■ <br />