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Waste Tire Su. _,dy & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 - 114 3 6 6 5 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part_A- Survey_ - _ -_ - _ —_ _ -___ _-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I' Inspection Type (Fill one) <br /> Site Suffix: (� <br /> / wC / o4 7 7 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 2 If Referral,choose referral type(Fill one) <br /> Identifier: sly O CHP 0 CIWMB 0 Complaint O Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> IS�ev <br /> Physical Address <br /> /6i6 k u.«c coa— 41 <br /> 9K;Zj o Inspection Date D 7 / ,� 6 / 0 <br /> Time In Time Out <br /> Business Rep /J Title 0 AM 0 AM <br /> 0 PM / ,p� SPM-- <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 /> � � <br /> Active Passenger ® Generator Q Outdoor <br /> O O Closed O Altered <br /> GPS Latitude � Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler O 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 /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: § <br /> Comments <br /> -e Zj A-7, r� - G� )4o ren_, ,-c Lz,—j-04 <br /> Inspection Form Included: <br /> Comments Included: � <br /> Business Rep's Signature Phone Number Inspectors Signa tu a Phone Number <br /> ILAINSTRUCTIONS ON BACK [Correct:* Incorrect ; �, ,�/ E X A 1 f 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ■ <br />