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Waste Tire SL ay & Inspection Repor: Inspection Report Number <br /> Ri Stateof California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140898 <br /> California Integrated Waste Management Board <br /> IFPart A_--Survey BLUE OR BLACK INK PEN <br /> - - -- -- - - <br /> Business Profile Inspection Details <br /> TPID- ` /+ v - O ` Inspection Type (Fill one) <br /> Site Suffix: `� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: Sze �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other j <br /> - - _ _ <br /> Business or Facility Name -- --- --- - <br /> Inspected By Inspector <br /> � aw <br /> 3 _ } <br /> Physical Addres �'J ( 49 <br /> 70oo ff c b,eZ Cu,,6-s Blvd. <br /> CAInspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ® PM ® PM <br /> -- - ---- - ---- - - - Operational Status Tire Type I Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> t7 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <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 /> 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 /> .. r _ __. - —_.._ .. <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 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 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 j (Required for NOV or EXT), <br /> 0 O <br /> 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 <br /> ® in Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> — -- -- -- _ 1 YI S ae Ems_011- f S --G�i'f G�/ <br /> lTLtJ G C�G�vY1�LJ <br /> iattc r /w kms[ -- - J <br /> Inspection Form Included: <br /> Comments Included: ® <br /> Business Rep's Signatr Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK °Correct:* Incorrect: X i �/` 'x 1. I ' 2 3 <br /> ■ ' © <br /> White Copy:CIWMB Yellow Copy:Oerperatorr Pink Copy L A ■ <br />