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® Waste Tire SLOey & Inspection Repod4o Inspection ReportNumber, <br /> `A CIWMB 8111(N w 04/04) ryu 1 1 1086918 <br /> State of CaCalifornia Integrated Waste Management Board Survey Form P a J e _ <br /> Part A- Survey) ) i - Inspection Ins a Details --_ BLUE OR BLACK INK PEN <br /> Business Profile , k�l�t. p <br /> � � <br />} TPID- ,-, � Inspection Type (Fill one) <br /> Site Suffix: 3 �j ��� t t_U 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> .Local � If Referral,choose referral type(Fill one) <br /> Identifier: /{ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physical Address ! bd <br /> Street Inspection Date _ I ± <br /> S�ate�—�1F�ode ' I—._.. <br /> f l <br /> - - -' — - - -- Time In Time Out <br /> r: _-._ <br /> 0 AM <br /> Business Rep Title r O PM . O PM <br /> w L �! LLL ,,,LLL <br /> t rOperational Status Tire Type Business Role Storage Type <br /> Fill one only) Fill all a Fill all that apply) ll all that apply) <br /> ( Y) ( apply)! ( Pp Y) Fi <br /> ( ', <br /> (D Active 0 Passenger Q Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> �I 1 10 0 Inactive 0 Truck <br /> Longitude - � ,[Tj I I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer @ 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 <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 M / M / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0`1 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0I0 - - -- - <br /> 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 /> 0 0 (Other: § ---- - - - <br /> Comments ,�Ol a 1� •^ Il <br /> Inspection Form Included: <br /> p 0'. , <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i E X �P L i ' <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />