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Inspection Report Number <br /> Waste Tire Su y & Inspection Repor' , <br /> CWMB 81'fornia <br /> (New 04/04) Survey Form Page 1 Il - 1088084 <br /> California Integrated Waste Management Board y - .7 <br /> Part A- Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br />+ TPID- j ` + _ + Inspection Type (Fill one) <br /> Site Suffix: , 3 , `� 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: - r, 1 J Ott' ilii ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L ` _ Inspected By Inspector <br /> '.t C t't I �,eT s i1 Q t,t(`n�2.t J►(:_> , 1'�C I �{ _ (� Q r , <br /> Physical Address I " I AC r,, C` (- <br /> Street <br /> i + ` Inspection Date <br /> oCl��U <br /> Cit,- State ZIP Code <br /> C3�( I' Time In Time OutJ I <br /> Business Rep Title 10 AM L� {` 0 AM <br /> 0 P 1 QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) e <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m Q Hauler Q Indoor <br /> _7� 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that appiy) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 I@ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in Compliance - No Violations <br /> Q Q Other: § - — - --- <br /> Commentsof kv I(��k _ \ ( _J ` ---� 1'Q- r i ! -` / <br /> riJ. <br /> Inspection Form Included d <br /> 77. ..,_ <br /> Comments Included: Q Business Rep's Signature Phone Number Inspector's Signature Phone , <br /> p' g p g e Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X C X i A MI P I L I , � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />