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Inspection Report Number <br /> Waste Tire Sur y & Inspection Report <br /> ili.' State B California I 1 - 1127516 <br /> ew 04/04) <br /> California Int grat d,81 WastJe Management Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I r^ I Inspection Type (Fill one) <br /> Site Suffix: l W 3 } - O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: (�an J o(, ju)i n C�� v� 0 CHP o CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> 0 7i <br /> Physical Address 3 - ES <br /> A\ 1So UQ (Za. JJJ WWWW JJJJ <br /> Inspection Date I l � � � � o <br /> Time In Time Out <br /> Business Rep Title a C 0 AM O O 0 PM <br /> J <br /> SPM is <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 /> Q Active Q Passenger o Generator O Outdoor <br /> GPS Latitude <br /> O 0 Closed Q Altered Q HaulerQ IndoorN <br /> ' /A <br /> O o Inactive Q TruckhjA NIA <br /> Longitude - o Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer o Auto Repair Q Trucking Fleet o Government o Retreader Q Dismantler o Tire Derived Fuel <br /> Used Tire Dealer o Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> ------- Q Notice Of Violation Q Extension <br /> o 0 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 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / m / m <br /> (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 o 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 Q Referred/CIWMB Enforcement <br /> Q o 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ _ <br /> o 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 10 1 o Other: § <br /> Comments 19 f�Ot�11 Wc( <br /> —Ek\Aid �, (ADC--XIX Q6WO -CAA --) i LIXS)n(ss_ <br /> Inspection Form Included: Q �J�CJ►��'v- �- ! _-1 lO��� /`�- <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr t: ncorrect: j '}C �,%,IWy P L l 1 1 2 l 31 62081 <br /> White Copy W Yellow Copy:Operator Pink Copy:LEA <br />