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E aWaste Tire $00y & Inspection Repe-",*Inspection Report Number <br /> State California <br /> CIWMB 181( 04/04) <br /> Il - 1141337 <br /> califomia Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_- -__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: , � 6 l -7 5 ® Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local �� � If Referral,choose referral type(Fill one) <br /> Identifier: 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> sla/-4on Pat+ 1)4-Y)C+ <br /> Physical Address <br /> oZdD 1 C3 <br /> f (� Inspection Date "► <br /> � 0 l <br /> 1. <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 1 0 -o PM -- PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ® Active ® Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude – l 1* OTR Q End-Use Q Container <br /> Q l Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber (� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �� Z--�— <br /> iCla <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A: HAULING AND MANIFEST REQUIREMENTS �Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 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 <br /> M / m / m <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 (Required for NOV or EXT) <br /> Q O <br /> 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments k� <br /> -Air) __vzb-Lo ,T 2w_S- car _A o�- r <br /> Inspection Form Included: Q <br /> V4-.3 13q <br /> 1 Comments Included: QL �7� �ttu Business Rep's Si at a Phone Number Insp s are Phone Number <br /> INSTRUCTIONS ON BACK GorcQt1 *44 W P 62081 <br /> White Cop : MB Yellow Copy:Operator Pink Copy:LEA <br />