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® ra Waste Tire Sulky & Inspection Repor*Inspection Report Number <br /> State of California <br /> CIWMB grated 1(New04/04) Survey Form - Page 1 I 1 - 1127513 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ - _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - M - - Inspection T -- <br /> Site Suffix: v P Type (Fill one) <br /> Site Su <br /> • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: somJ �jU 1� 11 r� wn 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `�I Inspected B <br /> PG 4 P y Inspector 1 <br /> Physical Address "S - !� 1 &n CS <br /> C A <15 aoq Inspection Date / / O <br /> ' ) Time In Time Out <br /> Business Rep Title I <br /> Q AM Q AM <br /> c1�(�1,1 �'.. � �U11 S 1J 1.S F��arY'N�1� � D � PM � 3 � � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active * Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude / <br /> 0 Hauler 0 Indoor N <br /> GPS A <br /> O 0 Inactive �Truck <br /> Longitude - 0 Planned ® 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 ® Other j��,l 11� RPV,C.Q, I 1`u, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rENF®RCEMENT`STATUS <br /> ,. <br /> Ap <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> NEW 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 Date0] / � M0 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/ClWM6 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 0 Other: § t _ <br /> Comments I 1 I ��S <br /> O b� JCA I <br /> df 0� L Z Lc�rm <br /> IKI 161A (k<ACk wirA4oJ-' ,4'$J1qdr LA A V�r I ju to <br /> Inspection Form Included: 0 ` <br /> Comments Included: 0 - ---- G�/ �ab -ae / _ IJ���jV" --�V 48-31-7A <br /> - - <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK 1112 3 62081 <br /> White Copy: W Yellow Copy:Operator Pink Copy:LEA <br />