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Waste Tire Sulf�ey & Inspection Reporo Inspection Report Number <br /> A <br /> CIWMB 181fornia <br /> (New 04/04) <br /> Il - 1143774 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I'Routine Q Re-inspection Q Referral O Observation <br /> Local couIf Referral,choose referral type(Fill one) <br /> Identifier: Ski) J oQ111U,(fi n O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> �onr Facility Name Inspected By Inspector <br /> Physical Address ca` 31 IE O 1 pp <br /> 1�2n ScAo <br /> \Sso 10&XS6LCJ <br /> S' &vO r\ (A <br /> 1534 <br /> Inspection Date a I O <br /> Time In Time Out <br /> Business Rep rr Title O AM 3 0 O AM <br /> \C S+ --- O • PM PM <br /> M O L y '�um� NS Q1 i <br /> - -- - - -- --- Operational Status Tire Type Business Role Storage Type <br /> /I/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) X <br /> f l* Active Q Passenger O Generator Q Outdoor <br /> O Q Closed Q Altered IA <br /> GPS Latitude I Q Hauler Q Indoor <br /> O <br /> Q Inactive O Truck <br /> Longitude - 0 Planned OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) F0tu1f} <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 11 r <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ®Other VIGI� nu�(1�ctLfe(' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O -14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 O Other: § l, <br /> Comments ,(A d1� ►1�5 Q,(�( » �� I S <br /> _(_�OA va_��IOM4 co�_ 4_c�_Waf(V <br /> Aos-�,rl�I cervi � r-, <br /> !inspection <br /> Inspection Form Included: 0 <br /> Comments Included: * <br /> Ikusess "� 51%-Ip's Signatures Phone Number Inspe or's Signat a Phone Number <br /> -- - - -- - <br /> / � 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect N ? P I ; 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink p <br />