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Waste Tire �y & Inspection Reps* Inspection Report Number <br /> 117 State of California <br /> CIWIVIB 181 04/04) <br /> California Integrated Was eemT 1 <br /> ManageentBoard Survey Form - Page 1 i i 1127942 <br /> Part A- Survey -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- O Inspection Type (Fill one) <br /> Site Suffix: J _` I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: IS ��q�j-�.1 !1 �Jr�„4n— <br /> — t0 CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name I ' 1 w� Inspected By Inspector <br /> C��rLS CpSibn Allam 3 <br /> Physical Address <br /> Inspection Date <br /> `�ju,u cA �S�y <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> --q J 0 PM -- --- _-� � �- ® PM <br /> ---V- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 16 Active • Passenger • Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer •Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O 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 /> Q ! Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Re istration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m / <br /> O ® 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 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 /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: § <br /> Comments r� , �^J <br /> r�OCJ f -- <br /> sex, <br /> Inspection Form Included: <br /> Comments Included: (�tJ► <br /> usi s gnature Phone Numberjspec 's Signature Phone Number <br /> INSTRUC S CK ; Correct:* Incorrect � � � � XA ,� � � � � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py: © ■ <br />