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Inspection Report Number <br /> Waste Tire Su yy & Inspection Report <br /> aaa. <br /> IFIL State of California <br /> CIWMB 181 04104) <br /> I 1 10 8 6 9 7 2 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A-Survey _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Ll /� Inspection Type (Fill one) <br /> Site Suffix: / C 1-1 I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. � .i� ��l ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B Inspector <br /> P Y p <br /> Physical Address 14 �! q ' 01 l �1eedV� <br /> JInspection Date <br /> ac 04 <br /> Time In Time Out <br /> Business Rep Title / 0 AM /�1OAM <br /> / ® PM V ® 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 /> a /C� Q Active Q Passenger Q Generator Q Outdoor <br /> D ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V r AHAULING AND MANIFEST:REQUIREMENTS <br /> -- <br /> Q � Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance.Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date M__ <br /> / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> i <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 p No Violations <br /> Q Q § <br /> Other: p�,-�7��� /� , c <br /> Comments VV�IU O'Ki��� `t,, s <br /> - Ci L-fu k.S r-e' UC9t e e110W_kP <br /> ' <br /> Y_ -It-q aMVLA_4 <br /> n o -QJ <br /> Inspection Form Included: Q <br /> Comments Included: — - - "' _L7 <br /> Q Busin q6#ep's &24Wure Phone Number lnspectgrzs Signature Phone Number <br /> INSTRUCTIONS ON BACK XIAIMIPILIEI 11 2L31 62081 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />