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Inspection Report Number <br /> Waste Tire Su ey & Inspection Repor, <br /> State B 81(New04/04) I 1 - 1127913 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � C' _ � 1 Inspection Type (Fill one) <br /> Site Suffix: ` b I © Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ(,( I,�,1r\ <br /> rn J C�-l�,'rl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �7- Inspected By Inspector <br /> na 1irtlSPhysicYldrass"M' <br /> CI�},^ 1�005 Inspection Date I I l <br /> ♦ , Time In Time Out <br /> Business Rep Title 0 AMQ AM: J- 5 OPM <br /> PM <br /> A eA Mu4" Mao"es <br /> V - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator S Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler � Indoor <br /> p Q Inactive Q Truck <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 /> IS 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 /> VA 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 Date 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 /> 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 /> 1010 Other: § <br /> Comments �fWit�S tnS(�G(.�iUll t71 r�(14 nn 1�1g� 117 1�--� i�i� �UTDS �vW� 01l <br /> Inspection Form Included: <br /> Comments Included: Q� <br /> ess Rep's Si ature Phone Number Inspe�r'sSignahrePhone Number <br /> v / - <br /> INSTRUCTIONS ON BACK Correct. Incorrect X �. �/ � A i 62os1 <br /> _ -- t=I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />