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Waste Tire Sal, ay & Inspection Report Inspection Report Number <br />° fornia <br />C�wMB 811(New 04/04)I 1- 112 7 4 8 3 <br />California Integrated Waste Management 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: 3 g O I 0 Routine Q Re -inspection Q Referral Q Observation <br />Local r"' If Referral, choose referral type (Fill one) <br />Identifier:SAY) Lk1n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name V Inspected By Inspector <br />111 aVFAwk EejAs -Ib1 <br />Physical Address 3 &n &Cook <br />Inspection Date I <br />Time In <br />IM <br />Business Rep Title I O O AM <br />I 0 PM <br />y Operational Status Tire Type <br />Tire Count (Whole/PTE) SS <br />7 (Fill one only) (Fill all that appy <br />' `J 0 Active I@ Passenger <br />O Q Closed Q Altered <br />GPS Latitude , <br />IJ Q Inactive Q Truck <br />Longitude - Q Planned Q OTR <br />Business Tvpe (Fill all that apply) <br />® New Tire Dealer Q Auto Repair U Trucking Fleet U Government U Retreader <br />I 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 <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 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 <br />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 <br />Q Q 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />• Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q Q Other: § 1' J, <br />Comments f&J6,, _ tri, 0oiii)Y\ c,etAar <br />� on �1i'5 At4tj Gtnl 11i <br />0 <br />Time Out <br />5 0 O AM <br />0 PM <br />Storage Type <br />(Fill all that appy <br />® Outdoor <br />Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />I* Notice Of Violation Q Extension <br />Compliance Deadline <br />/ BE. <br />Date 6 <br />(Required for NOV or EX7) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations <br />v io a tin___ til n <br />S � (.1%1 Uq a n d1 �/�—o <br />;pection Form Included: Q � )+�Q <br />Comments Included: (1f - --- - —-�1 L -O -- <br />Business Rep's a Phone Number Insp - tor's Signa re Phone Number <br />--- -- 62081 <br />INSTRUCTIONS ON BACK Correct:6 Incorrect: X)r' E X I + JEJ I C 3 <br />L— — — ® ■ <br />White Copy: CIWMB Yellow Copy: Operator Pink opy: A <br />