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Waste Tir ey & Inspection Rer <br /> Inspection Report Number <br /> 9Sff` State of California I S, 112-7584 <br /> CZEI181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> _ Insp�:ction Details <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: ' �J f Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: e� � �1 ! � I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address } �–i <br /> stee< <br /> _ Inspection Date 9 n € <br /> C <br /> In TiOut <br /> 1.. Time me State ZIP � .dw <br /> AM t 3 O AM <br /> Business Rep Title <br /> }} <br /> O PM _ I L. J€ O PM <br /> �� t <br /> 14 <br /> Operational Status Tire Type Business Role storage Type <br /> (Fill one only) (Fill all thatapply)� (Fill all that apply) (Fill all that apply)+ <br /> Tire Count(Whole/PTE) <br /> SI-7 Active Q Passengel Q Generator Q (outdoor <br /> Latitude I i0 Q Closed -0 Al <br /> tered <br /> Gas <br /> Q Hauler Q indoor <br /> ! r – Q Inactive Q I"ri.lck � <br /> )O Planned C� ' <br /> Longitude – Q O'1 R <br /> Q End-Use Q Con a€-ter v. <br /> Business Type -Ill all that a> l <br /> Q New Tire Dealer Q Auto Repair Q 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 ( { t ., I/n e 1 1( r <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. J 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 /> FFI / m / FrI <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 /> 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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> r <br /> Q Q Other: § � 1, � � ���..�� � I � L I <br /> Comments <br /> —�C��l`1� �4� � 1 r,t l Ai���,15 le'\(.d e �-( i 1(�� t f i i ��� r'^ - •l,t s''�I;�"(J <br /> Inspection Form Inc oded: Q <br /> Comments included: Q ' <br /> '� Ssfunature Phone Number Inspector's Siglaature Pi7oa-se Number <br /> 02081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X a/ X;A Mi P �� � , <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />