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Waste Tire 110a & Inspection Repoe*pection Report Number <br /> A <br /> Stale of California <br /> CJWMB <br /> 04/04) <br /> I 1 1141262 <br /> California Int grat d,Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey _ BLUE OR BLACK IN_K PEN_ <br /> Business Profile Inspection Details <br /> TPID- u Inspection Type (Fill one) <br /> Site Suffix: l l - b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdentifierJan `�J ��w 1 _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> A< ;T�z.ru�c✓ <br /> Physical Address - l 0 C [6� �n„t��I � <br /> _ <br /> l ' I t IG <br /> o2�t35 �: 6J<f�oe>' l-ve, <br /> 05 l Inspection Date G /'� / 0 C7 <br /> -J G` X152lJ <br /> Time In Time Out <br /> Business Rep Title Q AM � � Q AM <br /> • r <br /> v�C�UV\ S�fCkC('� � � ' � CJ ® PM ® PM <br /> ---- - _ --- — - Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whale/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � � K � �I <br /> ® Active Passenger ® Generator 1 Q Outdoor <br /> � Q Closed ® Altered I <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet 0—Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / ELI <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers J Referred/CIWMB Enforcement <br /> Q 0 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> C6 Yr rn et-2 <br /> Inspection Form Included: <br /> Comments Included: - - '- -- - `v_v ��/ 5 <br /> Business Rep's Signature Phone Number InsWt�rS gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: XE XP (- E1 l 62081 <br /> -- --- - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />