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Waste Tire Suzy & Inspection Report Inspection Report Number ■ <br /> 66e,. State of California S <br /> 6a 1"CIWMB,B,(Newb4/04) Surve_ y Form - .Page 11 Il 108f`8 317: . <br /> California Integrated Waste'Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection.Details <br /> TPID- -- )) - _---}---- Inspection Type (Fill one) <br /> Lf <br /> Site Suffix: I ( EEI Routine Q Re-inspection Q Referral Q Observation <br /> 1 Local —� �� t If Referral,choose referral type(Fill one) <br /> Identifier: b( E f ((t( Xt�. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> 1 <br /> (l< ��(� �� <br /> �'(� <br /> Physical Address <br /> To e7 I - <br /> Street <br /> Inspection DateT(n l ` r ( / <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM [a. <br /> FK_01 <br /> O AM <br /> + 16M D ® PM ® PM <br /> _ __ _ _LA f(/ ( al! Ct4t 6 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 11 <br /> Il (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> t <br /> Active (2) Passenger 0 Generator Outdoor <br /> 0 01 <br /> Q Closed Latitude Q <br /> I Altered <br /> C <br /> GPS m • Q Hauler Q Indoor <br /> o j Q Inactive Q Truck <br /> Longitude — O.-Planned D OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O.T.ire Derived Fuel <br /> I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q C/a i <br /> oI on' Q Crumb Rubber'/ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other }Y (' -'+�t t�Ejn <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS---- <br /> V <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q i Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q i 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 m / FT] / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Requited for NOV or EXT)Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q 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 Q'Referred 1 CIWMB Enforcement <br /> &1 Q 14 CCR§18461'-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. <br /> Q i Q !Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments --� <br /> ��tJ�'(•f"�`� iM t `-•C/( t�'�:5 ._��i r J (�`'�-�� t t _' 1._— ���-�: �`l/f t l—�t 1' ��' ?�`'� t.�(�!��. <br /> r t �). �fJ 'f t. � S <br /> i_1 / �•.`i yf v-( fl� '``_d .v. ''"' 'f._t �� is v fr _ t/,Jai.:-J _ or ��� <br /> _ + ti- <br /> ( %' In-, r t �' <br /> COW--ficom— <br /> Inspection Form Included: <br /> f / <br /> Comments Included � `� - <br /> - Business Revs-,Siggature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: , 62081 <br /> 1' White - - ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> � V <br />