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tr l u Waste Tire S y & Inspection Repor Inspection Report Number <br /> State of California <br /> CIWMB 181e ) 11412 5 3 <br /> CaliforniaalIntegrated WasttManagement <br /> Survey Waste Management Board y Form - Page 1 <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile j Inspection Details <br /> TPID- � 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: Fsa(N A A I r\ (OkA 1 CHP 0 CIWMB <br /> Q Complaint 0 Educational Visit Q Other { <br /> Busit)_ess or Facility Name <br /> Inspected By Inspector <br /> Physical AddressEa) <br /> Street <br /> Inspection Date <br /> _ City State ZIP Code I Time In Time l e_Out <br /> Business Rep Title Q AM I 0 Q AM <br /> 0 PM I PM i <br /> - <br /> U V�llc_f_ <br /> l Operational Status Tire Type .Business Role Storage Type <br /> 0 (Fill one only) (Fill all that.apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count Whole/PTE ' <br /> Q Active Q Passenger Q Generator O Out <br /> Latitude - -'-��o O Closed Q Altered O O <br /> GPS Hauler �' Indoor <br /> -- O O Inactive (D Truck { <br /> , <br /> Longitude - �=]� o Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> ( EqL4 I 1 � <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> VI A HAULING AND MANIFEST REQUIREMENTS <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires (E)Notice Of Violation Q Extension s <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB v I <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) # <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 /> 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 Qin Compliance - No Violations <br /> Q 0 Other: § <br /> r: <br /> r Comments ' <br /> ffi - V11 IA� �I <br /> -AAA S33 <br /> Inspection.Form 'Included: r `} f J <br /> , <br /> Comments Included: tiF , ,- - - �-� _�... �...�'.. ____ ,_ �..--rte _.�..._��-�---�-•_1��_- <br /> Business Rep's Signature )-Phone Number Inspector's Signature Phone, <br /> .Number <br /> y `� 1 - �� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) ? ;;, , p I- �! <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ I <br /> i <br />