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Waste Tire SAey & Inspection Reporo Inspection Report Number <br /> State of California CWMB `, {� ® T <br /> California Int grat dt81 Was eeManagement Board Surtl ey ®r1 1 1 1 age + 1141277 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: fnJ I ' V Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (^ '� If Referral,choose referral type(Fill one) <br /> Identifier. �{�r\ �a(Q `10 COI - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> r. 4 Inspected By Inspector <br /> Physical Address DE =oF U <br /> .......... ............I.................................. --------............ <br /> 11 Inspection Date i1 <br /> State, ZIP C'10life Time InTime Out <br /> Business Rep Title - .. AM i .. 0 AM <br /> Lu 0 15 O O PM <br /> _ . .. <br /> Operational Status Tire Type Business Role StorageType <br /> (Fill one only) (Bili all that aPKIY) (Fill all that apply)Y) ( ill alpha#apG( <br /> y)Tire Count(Whole/PTE <br /> 0 Active 0 '--)assenger 0 Generator 0 Outdoor <br /> O 0 Closed <br /> GPS Latitude D Aitcaed <br /> •� � � I 0 Hauler 0 indoor <br /> — 0 Inactive 0 Tiuck <br /> Longitude i0 End-Use 0 Container <br /> I I 0 Planned 0 OTR <br /> Business Tyne (Fill all thaf apoly) ' <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 0 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 /> - --- - — -- -- 0 Notice Of Violation 0 Extension <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 <br /> 1:110 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB / El <br /> 0 0 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> h <br /> -�o �'k C�6 C)�N o A —4—C \(Q-.((N <br /> Inspection Form Included: 0 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct;® incorrect: X 52081 <br /> " , E t F L 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />