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Waste Tire Sup „ey & Inspection Report Inspection Report NumberState of <br /> ■ <br /> CIWMB1811fo(Nw04/04) SurVe Form - Pa e 1 I1 - 1141050 <br /> California Integrated Waste Management Board <br /> 'art A- Surve y BLUE OR BLACK INK PEN <br /> Business_Profile Inspection Details. <br /> TPID- L] � -7 L� � � Inspection Type (Fill one) <br /> Site Suffix: I le Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� „j,,, , If Referral,choose referral type(Fill one) <br /> �V C.-OtJ1�L <br /> Identifier: '� C/r/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> c�V1 <br /> Physeal A ressCA q_j3go ( xj1n�1✓"l <br /> Inspection Date / 0 ZLXL l 1 d <br /> Time In Time Out <br /> Business Rep Title o r O AM O AM <br /> • d e PM 2 40 PM <br /> I�auee�m-CLPi ' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �� L/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ®Active ® Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer ®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 -1-HAULING AND MANIFEST REQUIREMENTS - - <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> QQ 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date T / FTI / Fn <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 O <br /> 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 /> Q Q Other: § <br /> Comments <br /> n Corn n-m>�rl,f� K - - <br /> Inspection Form Included: Q ,�..�� <br /> Comments Included: — — -- Qo Y� 73 <br /> usiness Rep ure Phone Number In Signature Of Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X I A MI PA I E j 112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LE ' ■ <br />