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Waste Tire Sub .ay & Inspection Report Inspection Report Number <br /> CIWMB 81'(Nw04/04) Surve Form Page 1 Il - 1143621 <br /> California Integrated Waste Management Board Y - J <br /> Part A- Survey_- _ __ _ -BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ( O <br /> Site Suffix: l ( © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ..J��n J 100, ul (, C�un�1� - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName 11 1 J Inspected By Inspector <br /> Fo0�,"l` S,nr['q,( y l� 39 - C� a <br /> Physical Address EO <br /> Inspection Date u <br /> Time In Time Out <br /> Business Rep Q Title (� ('� AM Q AM <br /> j V O � PM � ® o • PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) j , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _' 0 Active ® Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <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 fj Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> ------ - —__------ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 1 <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q li PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 /> i <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/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 ® In Compliance - No Violations <br /> 01 Q Other: § <br /> Comments t n.n._�l(!LRc 1 lam lbyGIJ� <br /> - 1Q) _v <br /> 'Inspection Form Included: ^, ��q (// <br /> Comments Included: 7- 36- y �r',Signt,re <br /> �IKP► `� <br /> J <br /> us Hess R9 <br /> ep's Si nature Phone Number InspPhone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect X ��(4 p JLJEJ 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />