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Waste Tire Suk _ ay & Inspection Report Inspection Report Number <br /> att State of California <br /> CIWMB 181 <br /> California Integrated Wast(New <br /> 04/04) Board Board Survey Form - Page 1 Il - 1140930 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( _ ti Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.n J0"Lkl n (OvAt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> e av 2s � c u,clr�i n _ 'I <br /> Physical Address 3 J I Q <br /> -7 S . 0 WA A J e, UUU <br /> �/tW ne�� Inspection Date � a � � l � I <br /> `�J Time In 1 Time Outl <br /> Business Rep Title ( � 0 ® AM C *AM <br /> V QPM O J QPM <br /> - - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d <br /> le Active Q Passenger ; ®Generator s Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> king Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair Truc <br /> Q 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 Date M / m / m <br /> 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 (a In Compliance - No Violations <br /> Q Q Other: § /1 <br /> Comments <br /> 1I <br /> Inspection Form Included: Qi n / •�'Q <br /> Comments Included: �r �l7g <br /> Business Rep's ignature Phone Number Inspe is Signature Phone Number <br /> - <br /> -- - 62081 <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect: X Ak YX A M L I �1 2131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />