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® '• Inspection Report Number <br /> Waste Tire „survey & Inspection Rep..rt ■ <br /> State of California <br /> Form - PafuYe 1 I 1 - 1141047 <br /> California Integrated Waste Management Board J J <br /> A- Survey- BLUE OR BLACK INK PEN <br /> ness Profile t Inspection Details <br /> I NID- Inspection Type (Fill one) <br /> Site Suffix: J 0 LI ) l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: ScxA Jc)(XCf"A� (r/Ql��' v/ - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> C-rc oc\rc� �_C�Vj\Scc pe, - <br /> Physical Address , l l �}l6,, �t.V►'lkx� <br /> Inspection Date / © -s V <br /> i re,�c <br /> CA q53041 ) <br /> Time In Time Out <br /> Busin ss Rep Titl O AM O AM <br /> PM PM <br /> - - � ��txrc� <br /> — - - - - Operational Status Tire Type Business Role Storage Type i <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Q Active Passenger 40 Generator Q Outdoor <br /> GPS <br /> Latitude O +® Closed Q Altered Q Hauler Q indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> .� 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 zxtA�'- �. !�rn C-Cjyrl�414 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V A HAULINGAND MANIFEST-RE-QUIREMENTS - - --- - <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) j <br /> Q O - - - - <br /> 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> i <br /> ,...Spection Form Included: Q <br /> G 1 <br /> Comments Included: <br /> Busi - -. -I-gature In o - nature P�ho6ne Number <br /> Phone <br /> ern ���na <br /> . .—- ----- - <br /> INSTRUCTIONS ON BACK Correct. Incorrect 62081 <br /> x � , <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />