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Waste Tire Eoey & Inspection Rep0,71Inspection Report Number <br /> ■ j <br /> State of California ■ <br /> CWMB grated 1(New04/04) Survey Form - Page 1 Il - 1140654 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( 6 3 V le Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / ,j, If Referral,choose referral type(Fill one) <br /> Identifier: �� ��� lLy CEJ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (` Inspected By Inspector <br /> CvYi Y1 W Ci UZ� S C �1 <br /> Physical Address V 1 A[ m i_�Je <br /> �J / <br /> 1CC) (A)cscC-ryle_'r r 1 <br /> Inspection Date t 7 <br /> Time In Time Out <br /> Business Rep Title `` AM AM <br /> �� �Ct,►�ll �_Vc�_. —f'r�tl�7lC� �?� / 0 0 C 0 PM � � � � - 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - � j <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned J ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V I AI HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension i <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 1 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® in Compliance - No Violations <br /> 0 0 Other. § <br /> Comments <br /> see-- <br /> Inspection <br /> Inspection Form Included: 0I ` l / <br /> Comments Included: ® — WZepgnature <br /> es Phone Number I s to s Ignature PhoneNumber <br /> INSTRUCTIONS ON BACK orrect:* I correct �/i X (_ 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: © ■ <br />