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Waste Tire ouk �ey & Inspection Rep <br /> ��L Inspection Report Number ■ <br /> State of CaliforniaCJWMB 181 T 1 <br /> California Integrated WasNe Management Board ew 04104) Survey Form - Page 1 1 y 1143802 <br /> Part A- Survey — _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: D, I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: eta Jmtj w(� (O-U � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> 54-E T�"Lk '- -v v� cz- 6 a;r q - n I <br /> l. <br /> Physical Address SCOato <br /> S <br /> Vs O's 1\1 yv� 0�. - - —� <br /> �� ��� Inspection Date r / <br /> � � <br /> � � <br /> fl 'u �n <br /> Time In Time Out <br /> Business Rep Title 1 0 AM 0 AM <br /> (SVAQPM aPM <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 /> x-11 <br /> 0 Active ® Passenger Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 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 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 Datem / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <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 /> 02-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 14 CCR§18460. <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 /> - (10 cvreqa n-� C01)CdA. - - - - - - - - - <br /> e: �. w �� - uses � '►fie.AS` �C_Cc iS es i.�4 �, f� QA F__ <br /> Inspection Form included: 01� <br /> Comments Included: OI �Wlr� <br /> usiness Re 's nature Number Ins�s Si nature Phone Number <br /> - P Phone p 9 — <br /> 62081 <br /> INSTRUCTIONS ON BACK C ect: Incorrect: t , Ex A M n 1 ! 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L ® ■ <br />