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Waste Tire Sufty & Inspection Report* Inspection Report Number <br /> State ttE'Ji <br /> CIWMB <br /> Survey Form - Page 1 ( 6 - 1 6 2 6 8 76 <br /> CIWM81B1(New 04/04) Y /y <br /> California Integrated Waste Management Board {�•� <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details l <br /> TPID- � � � � � 0 � _ � I Inspection Type (Fill one) <br /> Site Suffix: J <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ��A%� lJ G (tii Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'JJ Inspected By Inspector <br /> Physical Address J ��� <br /> RLi( 2— <br /> a <br /> a 19 E , /kle.,tf J e-nuw_ <br /> 0A9524 D Inspection Date 3 <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Awkr _ O PM 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 /> Ir Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned ® OTR O 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other i 'lufior Of f s le�tu�air <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCOMENT STATUS_ . <br /> �. <br /> Al' HAULING AND OANIFE;3TREQUIREMENTIS O Notice Of Violation Q Extension <br /> O 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 /> O o PRC§42956-Registration/Decal in Vehicle <br /> Oo <br /> 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements .pate m <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RgqulrsdforNOVorE" <br /> O O 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 ():',Rate:rr*d/CIWMB` Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> other: § O in I"yantpli rftaq • Ido Vlolatione <br /> Comments OtOnev' nL�� �t�� ��i�J�2 �✓C� � f' l,'�L�S e ale i't/iGL{il .-S�S , <br /> Wi re tvh;ti 3 f ay 105 --ft) SpeaL LO;th <br /> r�C�C�✓ Chi i� C 1 vJ M,8 W a S+:I 2 'Pre Pro p ra pi . NzW G v tjAI r. <br /> Inspection Form Included: Q .���- ` 7^� L1/ <br /> Comments Included: Q . <br /> Business Rep's Signature Phone Number j I. pector s Signature Phone Number <br /> INSTRUCTIONS ON BACK Garr >vstT tltfifCl" j iM 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />