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Waste Tire Su, ey & Inspection Repots Inspection Report Number ■ <br /> 89119 State of California I 1 - 1140742 <br /> ew 04/04) <br /> California Int Brat dlWaste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y� ( Inspection Type (Fill one) <br /> Site Suffix: )' 0 ( - U <br /> ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localt^ If Referral,choose referral type(Fill one) <br /> Identifier: <br /> an <br /> {1 J p a a��� 01,x(1 1� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> - - <br /> IJ Inspected By Inspector <br /> Phy(�cal <br /> �o;Address�. ul`�l i n I`n�1 l er ctkS 6)5k. 3 _ 0si <br /> � � cn E�zv <br /> lay 3 b 5 - f.,F- k ad . - <br /> O 9S33b Inspection Date / V <br /> �� Time In Time Out <br /> Business Rep Title 0 AM O PM � � � AM <br /> PM <br /> 7011" 0 s - mslr• <br /> -- - � - - -- - - - --�1-- ---- Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i" 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O ® Closed 0 Altered NiI <br /> GPS Latitude 0 Hauler 0 Indoor JA <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) Fl)I��1tTT <br /> 0 New Tire Dealer 0 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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 j PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 <br /> m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 ® In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments QuI� JIV <br /> .—_4 <br /> x_' <br /> 00 VI al <br /> y <br /> Inspection Form Included: <br /> Comments Included: - /4� /"`y - C�6�one <br /> B SignaturePhone Number Inspect s Signature Num er <br /> - - <br /> --- - -- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: i �: 62081 <br /> X � ( I 6�LE <br /> I `I3I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />