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■ Waste Tire _.Arvey & Inspection Repk,. t Inspection Report Number ■ <br /> _= State B California Il - 1140677 <br /> 04/04) <br /> California Int grat dt81 Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details - - -----— <br /> iPID- 2 Inspection Type (Fill one) <br /> Site Suffix: 6 J -7 o ' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � ` �Q�y� Co�.,n. If Referral,choose referral type(Fill one) <br /> Identifier: 0A J (Z, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> A! ex -77y-e-s � 9 /] <br /> Physical Address i 0 �,��`� A/461 (0`) <br /> p <br /> /6 s 01 -1 t/r rr A t <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM Q AM <br /> ' D © do PM O ® PM <br /> -- - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f�/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 01 0 Active 0 Passenger ® Generator 0 Outdoor <br /> �t <br /> O 0 Closed 0 Altered IVIA <br /> GPS Latitude 141 0 Hauler 0 In <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 I ENFORCEMENT STATUS <br /> V , A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires j <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. I 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 /> 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 0 In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments --jn _L.ZLt I�► 1 <br /> -Ala-V, AbWs, a,c Q \ 0P G)9(.e_ k /Naffs Pr�bd- <br /> rxw 4,)4c-r &+--fh iS s,�e Us t�ZG <br /> ikCC0MnienA ,, 0-1 <br /> ..�pection Form Included: 0 <br /> Comments Included: 0 — - — — —— � <br /> Buslness Rep's Signature Phone Number In _ s i ature_ _ Phone Number <br /> INSTRUCTIONS ON BACK Correct I* Incorrect i � O f 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />