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M j Waste Tire Sup Bey & Inspection Report Inspection Report Number M <br /> CIWMB 81'fornia <br /> (New 04/04) S urVe Form - Pa/uye 1 I 1 - 1143596 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q I Inspection Type (Fill one) <br /> [ <br /> Site Suffix: 5 U J a. S O , 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: S(,�(� J0 l,(1 n (()IAQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �z\k C (31u�i aS s C� . - l a <br /> Physical Address J ` 1 g(f'1 Esco�v I, <br /> Avjor,uw� 51 , <br /> C - <br /> A452c3 Inspection Date 4 0 <br /> Time In Time Out <br /> Business Rep Titleh O AM O AM <br /> ' l V <br /> G 5 <br /> w�.0 t1 5 l Ce. v 0 PM (I PM <br /> ��- �c.�hc,n - - - - _ ----- <br /> - - - - - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5 l� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J V Active Q Passenger ® Generator ® Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR O End-Use I Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> - - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ® I O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> ® Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / MO7 O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB M5 <br /> O I O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments 1 1 C�rl(� 11�17U17� GS , <br /> Inspection Form Included: Oj A 6� Nu <br /> �,Comments Included: " ,L� v�- � - I � &k ao ), Bu ness Rep's Signature Phone mber �Inp tot's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X : <br /> Copy: IWMB Yellow Cop <br /> A P L i 3 <br /> - . - - - --—— <br /> ■ White ------ <br /> Cy:Operator Pink Copy:LEA ■ <br />