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Waste Tire SuSey 8c InspectionRepOi Inspection Report Number <br /> State California <br /> B 04104) <br /> I 1 - 1108412 <br /> California Int grat dfWas eeManagement 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 I 5 IT/ f L' / I® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: 14 . 1 by 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> I Inspected By Inspector <br /> Physical Address,- ioT) Jit,_ra ---j <br /> tl 11 -se <br /> /03, 0V yj <br /> Str t�L A C{ � 3 ^1(/ Inspection DateI _1 <br /> JJJ <br /> r,ity State ZIP Code Time In Time Out <br /> Business Rep.. Title l , I ��AM F� Q AM <br /> OPM / ! QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) :: <br /> ^( <br /> /I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator .0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m . 0•-Rauler 0 Indoor <br /> T O 0 Inactive 0 Truck <br /> Longitude - I I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all th' t appy'" <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 Pre rlS I <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 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 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 Q In Compliance - No Violations <br /> 0 0 Other: § f /f� J I - <br /> Comments-Awl rr `� C 16A 4A J ow c h <br /> e , ' = _)pct <br /> i "moi t V JC4 t' •� c 5 Ft•t c�s" <br /> ja <br /> spec on Form Included: 0 <br /> Comments Included: 0' -- - <br /> ,�7, <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> • n" <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i- X A M p I� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />