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Waste Tire Su. ✓ey & Inspection Repor'L Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1143829 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- � -7 <br /> � 0 � Inspection Type (Fill one) <br /> Site Suffix: 6 3 -7 (a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localr V ,� j_ If Referral,choose referral type(Fill one) <br /> Identifier: �tC j�� �� f [(� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Ce_L-I cc E c-v►Prne-n-F <br /> Physical Address 39 l A tri�v �,, � <br /> fmarlipcxv" RL <br /> 5a ! Inspection Date 1 1 0 <br /> Time In Time Out 1 <br /> Business Rep Title I ®AM 0 AM <br /> ti�Cl.1l � . C.�G�C.i �j�';/ �WYt�� ! � � --� ._..O-PM- 6 C2, � l ® 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 /> f f I&Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® 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 le 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 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 M / m / 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 (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 I 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 /> �J <br /> Inspection Form Included: 0 <br /> Comments Included: ® Clrl .-Tv- CLOle—r - u <br /> Business Rep's Signature Phone Number ct !.gnel Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect ^ �/! T 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :LEA ■ <br />