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Waste Tire amu► _ ay & Inspection Report Inspection Report Number ■ <br /> �o State CIWMB California 11 - 114 3 9 6 3 <br /> California Ine grat d Waste 181 eManagement Board survey Form w 04104) - Page 1 <br /> Part A_-_Survey _ - - BLUE OR BLACK INK_PEN <br /> !Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: l 9 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 011) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I 11 J Inspected By Inspector <br /> Physical Address <br /> Inspection Date 5 1 <br /> CA 953'T7 <br /> Time In Time Out <br /> Business Rep Title S •AM o * AM <br /> I <br /> 1_ I 1 J O PM I v O PM <br /> J-- — -— 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 0 Passenger • Generator 0 Outdoor <br /> PS Latitude <br /> O 0 Closed 0 Altered A <br /> G 0 Hauler 0 Indoor <br /> O 0 Inactive 4DTruck <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 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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 M / Ffl / M <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 i (Required for NOV or EXT) <br /> 0 0 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 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 9-t1L�ltt �CS�C�3f11C� 0c', �S D�W7_�G((1(J� <br /> �1 e) \J'1 A&�iq S o S u res �--c.Cncg7rn. <br /> Inspection Form Included: 0 InQ <br /> Comments Included: �' <br /> Business Rep's Signature Phone Number Ins tor's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK � Correct:* Incorrect , I �;: �/ } 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ■ <br />