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Waste Tire Su. y & Inspection Report nspection Report Number <br /> i13 State of CaliforniaCWMB 04/0 <br /> 1 <br /> California Inegratd'81 WaseeManagement Board Survey Form - Page 1 I1 1127514 <br /> Part A-Survey _ _BLUE OR BLACK_ INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection-1 � 16 � � O � Inspection Type (Fill one) <br /> Site Suffix: i J "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ���` n If Referral,choose referral type(Fill one) <br /> 1 + 1 Q�t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Identifier: So,Y) J Q <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �jk'r\A e_ �;�1�w� EAp's-& <br /> Physical Address — I I` SC01d <br /> 50�30 -� . F f C.fr,04 J + v <br /> Inspection Date Q q <br /> Time In Time Out I <br /> Business Rep Title U O AM h Q AM <br /> I 1 <br /> say 0 PM v e PM <br /> 5 �1�.� 1c, �e,� �cr ► <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 /> Vart l A Inspection <br /> HAUUNG AND MANIFEST REQUIREMENTS MENTStor, Hauler and End-Use Facility li ENFORCEMEN _STATUS _ �I <br /> 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 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14.CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 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 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f In Compliance - No Violations <br /> Q O Other: § -- <br /> Comments p L� <br /> V'Woe �v 6��J'�(1c -) A n\'i S-- `` � u -� Ow 106 <br /> -tis nbici '. <br /> V c - <br /> Inspection Form Included: 3 17 <br /> 100t Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr c ncorrect: �/,� a A ,�, P L E I 2� <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />