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Waste Tire S & Inspection Repo"Inspection Report Number <br /> Y p <br /> State of California E <br /> CIWIVIB 11 - 1140752 <br /> Californialnt grat (New 04104) <br /> Survey Form - Page 1 <br /> Part A-Survey - _-_ - - BLUE OR BLACK_ INK PEN_ <br /> Business Profile I Inspection Details <br /> TPID- 1 y� � 1 � � � - © I Inspection Type (Fill one) <br /> Site Suffix: v ` Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type Fill one) <br /> Identifier: Jt�� LiA(� Cuu��r Q CHP Q CIWMB 0 ComplaintQ Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> £� cwM, 0o <br /> Physical Address <br /> alm �. M <br /> C n boos Inspection Date 1 � � � � � 10 ll <br /> Time In Time Out <br /> Business Rep Title 5 O AM 10 O AM <br /> QPM 19 PM <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 Q Generator Q Outdoor <br /> O • Closed Q Altered <br /> GPS Latitude �� Q Hauler /#q Q Indoor <br /> O Q Inactive Q Truck A <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 41 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 <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 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Numberfrom CIWMB <br /> Q Q 114 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/CIWMB Enforcement <br /> Q JOO <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Other: § _j <br /> Comments Comments un �Z — <br /> 0�1 - --- <br /> \_. - <br /> ' ' ups �c��.7�3g-cel S D, ILAin55, <br /> Inspection Form Included: Q i�'!'y' `�- • f� <br /> Comments Included: Q; <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> _ - ����� <br /> INSTRUCTIONS ON BACK E X'A !� P <br /> Correct: Incorrect Kip,- �— 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />