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AOL <br /> ■ .ire Wagte Tire .S�u ;& Inspection Report sp t Report"Number <br /> W <br /> State of California CIWM8181(New04104) "SUr , Form - Page 1 18 - 1 3. 3 l 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> 'TPID- _ Inspection Type (Fill one) <br /> Site Suffix_ - �.- —Hil0 Routine Re-inspection 0 Referral 0 Observation <br /> Local .; If Referral,choose referral type(Fill one) <br /> �,...��^'` n <br /> Identifier: .. `x 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 /> Street <br /> �� Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM 0 AM <br /> f� PM <br /> 0 mm • m 0PM <br /> ,r�I—�—�� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑y I I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> u+1_J (Q Active Passenger ® Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Inactive Truck 0 Hauler 0 Indoor <br /> 0 <br /> Longitude — 0 Planned 0 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 /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 0 ' A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> - - - 0 Notice Of Violation � Extension <br /> 0 PRC§42951 -Waste Tire Hauler Registration and.Transport of Tires <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 DateO <br /> M-3 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR'§18460.2-Manifest System Requirements for'Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement :, <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire'End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § f <br /> Comments (4 GG a 4, �:. <br /> _47 13 <br />{ +C_ .f rl c y L I :� ��r ,nr ✓.S' (,✓-,.?� <br /> Inspection Form Included: y f <br /> Comments Included: O _. ... . ... ------- <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X� 9 , 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />