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Waste Tire SG. ,iey & Inspection Report Inspection Report Number ■ <br /> State of CaliforniaCIWMB 04104) <br /> California lntgratdtWaseeManagement Board Survey Form - Page 1 T 1 <br /> 11 1143757 <br /> Part A- Survey BLUE OR BLACK IN_K PEN <br /> Business Profile Inspection Details <br /> TPID- O Q Inspection Type (Fill one) <br /> Site Suffix: p Q I a Routine Q Re-inspection Q Referral Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: Sao J OGS�tn �j�n� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> t — <br /> Business or Facility Name - <br /> C C f k 1 Inspected By Inspector <br /> Physical A,d�n S0� 1�0�; — <br /> J �vn CSco�o <br /> Inspection Date 3 � ` 0 <br /> Time In Time Out <br /> Business Rep l Title l / O AMI O AM <br /> vf I�1�U�'f, I.OUj�. -- 3-V 0 PM -- - � -.-- �-� -G PM <br /> ---- - ---- - --- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �] l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' J a Active Q Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use 4§ Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair &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 A HAULING AND MANIFEST REQUIREMENTS <br /> I Q Notice Of Violation Q Extension <br /> Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / M / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q i 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O <br /> 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 do <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 2b,-� \ ton <br /> ��S'• ' ,� --�S_�� �,i11�� S r �i f ril fN � UIQ �5 <br /> Inspection Form Included: 6 C I, <br /> Comments Included: — � JYt- '�� — <br /> I Business Rep��nature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: l E A E 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: ® ■ <br />