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M =e g Waste Tire Su fty & Inspection Report%spection Report Number <br /> State of California ■ <br /> CIWMB1811(New04/04) Survey Form - Page 1 Il - 1140863 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 't` _ f Inspection Type (Fill one) <br /> Site Suffix: / `/ 3 ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 43'1 ��, ,J w C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> C p Y Inspector <br /> Physical Address <br /> A, l��1 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> 0 QAM 0 A <br /> !'�.E L' j(', �,{7 S(1 yam• �rh:iNGL�� O ® P M o ;z -3 S ® P M <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 /> ® Active 0 Passenger ® Generator Q Outdoor <br /> d <br /> Q Closed 0 Altered Gpg Latitude Q Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned IS OTR O End-Use Q Container <br /> Business Type (Fill all that.apply) — <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ® Other T-\ <br /> Jirtr�ht 4 c-v- �evv'rt <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 O 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 /> Q O PRC§42956-Registration/Decal in Vehicle <br /> m [—n <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB m <br /> 0 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Other: § <br /> Comments <br /> war <br /> !inspection Form Included: 0 ,! <br /> Comments Included: 0' /` --- ��� ������G CZ�►��6 ` d6 z <br /> j Bu ess ep's Signature Phone Number Inspector's Signatur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BA Correct: Incorrect: . �/ E`X A P 3 <br /> X <br /> --— -- -- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />