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Inspection Report Number <br /> Ulf Waste Tire Su ey & Inspection ReportState <br /> E�1YZp fornia <br /> CIWMBf1811i(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 I1 1 1127515 <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r0Oe <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r— If Referral,choose referral type(Fill one) <br /> Identifier: Son 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 I u <br /> J Inspected By Inspector <br /> A ll�� Poot S pct 3 _ I n 11 <br /> Physical Address <br /> G - rb Wr �N ��` JJJ IIIJJJ.7UUU rtl IIJ -- <br /> Inspection Date <br /> V-,- , (A 1530 <br /> Time In Time Out <br /> Business Rep Titlel 40 AM r�O O PM 40 AM <br /> PM <br /> — Operational Status Tire Type Business RoleStorage Type <br /> Tire Count (Whole/PTE) <br /> U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � l � <br /> l Active ® Passenger 9 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive i � Truck <br /> Longitude — 0 End-UseO container <br /> 0 Planned OTR <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 ,^, 11 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other Pool //W0417U`►IIDn <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 /> 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 /> 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 1 0 Other: § <br /> Comments ,FaA Ui�1� Ui A Q _ln I.�MS <br /> ALI,- Foaw CCOU cts rLca�l' _U'U�4 I' cq- kault <br /> Inspection Form Included: 0 U p <br /> Comments Included <br /> usln s ep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr ct correct. End F mk P1 <br /> 62081 <br /> White Copy: W Yellow Copy:Operator Pink Copy:LEA <br />