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MWaste Tire ��I�y & Inspection Repo* Inspection Report Number ■ <br /> "' CIWMB 81California <br /> (New04104) Survey Form Page 1 I 1 - 1127937 <br /> California Integrated Waste Management Board Y - J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C 1 �s7 _ I Inspection Type (Fill one) <br /> Site Suffix: J '(7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: d J Ol w n c71Jl.(1 O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name tt <br /> I 1 1 Inspected By Inspector <br /> co <br /> Ads O_C.� 1.D�1 C�i G <br /> \ <br /> PhysS t� _ I 1 ,l <br /> ` l gen E5A6 <br /> CA Inspection Date i � O -7 <br /> C'Jll„�' Jdv Time In Time Out <br /> Business Rep Title � � l 5 10 AM 0 PM l I � � 0 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 /> O Active Q Passenger 41 Generator O Outd'o'or <br /> Latitude <br /> t) ® Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> D 0Inactive #j Truck <br /> Longitude — 0 Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair le Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 0Vi <br /> A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> O Q (Other: § <br /> Comments n 1 <br /> C\9-1 \A3GA��i <br /> - - NoyioUionSof CUP- _4 Qcn- <br /> Ilnspection Form Included:•Q' <br /> Comments Included. �)w;'Q — <br /> ,Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect "v �/; l E A L y 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink C py: ■ <br />