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nspection Report Number <br /> Waste Tire Su y & Inspection Report <br /> Slate of California I 1 1140849 <br /> CIWM'd1W"a <br /> (New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA- Survey_ _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- // _ Inspection Type (Fill one) <br /> GSite Suffix: 33 G � 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 11 Referral,choose referral type(Fill one) <br /> Identifier: , ,^w — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 l _ <br /> ,23(-)-,s ,N <br /> � I SJR <br /> Inspection Date <br /> s <br /> Time In Time Out <br /> Business Rep 1 2 Title,I / �r J O AM / O AM <br /> 0 / C ® PM � G � � 40 PM <br /> — -- - Operational Status Tire Type Business RoleStorage Type <br /> Fill one only) Fill all that a Fill all that a I Fill all that apply) <br /> Tire Count (Whole/PTE) 2 � ( ( apply) ( pp y) ( pp y) <br /> } 0 Active ® Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 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 0 Other - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> --------- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date / / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m <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/CIWMB 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 0 In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> i3riAA 71 l�C-+I`C4A d- 'n. Tln u C oi <br /> k-10 k <br /> Inspection Form Included: 0I - � Al' �'2�j tld�-'0G2 <br /> Comments Included: ®' <br /> Business Re ' S ature Phone Number Inspector's Signatur Phone Number <br /> INSTRUCTIONS ON BACK :Correa Incorrect: � 1 111213] <br /> 62081 <br /> White. <br /> Copy:CIWMB Yellow Copy:Operator Pink Cop <br />