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Waste Tire &ey & Ins Inspection Repo� inspection Report Number <br /> ==spa p <br /> 2 C WM13 California181 1i(New 04/04) - 11 - 1143683 <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 Type (Fill one) <br /> Site Suffix: l 5 1 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SON\ �p� `f\� f(,/ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address — <br /> Yrl ` <br /> Inspection Date _? I O <br /> L.. t A gP50Cz CJI <br /> Time In Time Out <br /> Business Rep Title i 0 AM 0 AM <br /> b ® PM C v' 0 '*PM <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 /> 0 Active ® Passenger (6 Generator 0 Outdoor <br /> O 40 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 1® Truck <br /> Longitude — 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other V (•}�,�I( P � <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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O ------ - _ . - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years II <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: — - <br /> Bus ss - <br /> Rep's Signature Phone Number ect r' nature Phone Number <br /> i� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect ?f A , F 1 2 3 <br /> _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />