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Waste Tire Sul&y & Inspection Repor'L p p <br /> Inspection Report Number <br /> CIWMB 811i(New 04/04) S U�,e�, Form - Page 1 I 1 - 1141289 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 Inspection Type (Fill one) <br /> Site Suffix: J jO ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` 1 If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: � `��( fJ (�)Va O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �1 r Inspected By Inspector <br /> v 17c) A f,6 r nee neer s> _ <br /> Physical Address 3 C r <br /> Inspection Date � � J 5- <br /> o�t 0 Time In Time Out l <br /> Business R(e�p,,, Title <br /> ® AM ® AM <br /> ��' i.JCL.vm �� VC.e�►1�' i� -�- � � � Q_PM � � � � e�j -Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> D ® Active ® Passenger ®Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer i Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> - --- -- - - - Q Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �;'.0 Referred/CIWMB Enforcement <br /> O Q 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 /> r� O Other: § I - <br /> Comments e- il'151 _U� 1 --C'toll._e C-yt S <br /> �/ <br /> Inspection Form Included: OI <br /> ryry// <br /> Comments Included: OI - - -- - -- - �`�✓ _F/b_3 <br /> Business Rep's n e Phone Number Inspe t S' na re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X X A, I �X 1112 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink p A <br />