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iea <br /> Waste TirL jui. .e� .A Inspection Re,_,e't k .,ection Report Number <br /> State B California Il - 1143803 <br /> CIWMB 781(New nage survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey---- -- -- - ---_ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection O � p � � Inspection Type (Fill one) <br /> Site suffix: t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: SC,(1 oactUa n Own 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By I Inspector <br /> Physical Address <br /> X310 E . Cc11�A , <br /> �^ q �� Inspection Date <br /> Ol 0 hint <br /> Time In Time Out <br /> Business Rep r/ Title <br /> �lin�.S O O AM O AM <br /> � 0 PM 1 3 o O PM . <br /> g� 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 app <br /> ly) <br /> 7IS Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 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 /> Q Notice Of Violation Q 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 (Required for NOV or EXE <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 Is In Compliance - No Violations <br /> 0 0 Other: § <br /> Commentsyt 01 (�;n�Ps lOr� U7c�T - (��1�i r�S (ANI 4SAO.'Ai" um <br /> X16 V%D�akkors n.r (LR-Ab tntcfn, Q <br /> N ok'� F�� 41501\ �r '31 41're, ep, <br /> ,Inspection Form �nc�udecl: 0 <br /> Comments ncuded: Q /1 O - �" --' � <br /> Business Rep's SignaturePhone Number spec is Signature — _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: vv� ��,, A P L � 1 2 3 62081 <br /> --- C .`h ` Q �� <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink opy: ® ■ <br />