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N='EE. Waste Tire Su*DjF Inspection Reportel ection Report Number <br /> ET 1 <br /> State B California Survey Form - Page 1 11 1127545 <br /> CIWMB 181(New nage) V � V y U <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> --- - <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: l 5 _3 ��/�'`/ ( ® Routine Q Re-inspection Q Referral Q Observation <br /> I Local i�, n/1 If Referral,choose referral type(Fill one) <br /> Identifier: `�C �.r�� Cir <br /> lQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - -- - — -- <br /> Inspected By Inspector <br /> �rvic�S� <br /> Physical Address Cf <br /> mlytif'-- Ale- <br /> ^��, Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM <br /> � <br /> �.� SVC, <br /> �j Q AM <br /> lb/C- SVC/ �� `� ® PM ✓ WPM <br /> - y -- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ® Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I_ <br /> Part B - Inspection of Waste Tire Dealer Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ... Notice Of Violation <br /> ---- - ---- __. _. . Q Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> I. <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date mm / Ell <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q ! Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years - ---- - I <br /> Q j Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance - No Violations <br /> Q Q (Other: § <br /> Comments- <br /> Inspection Form Included: d 1-to <br /> Comments Included: Qp, g sine e s Si nature Phone Number ature Phone Numberi kINSTRUCTIONS O BACK62081 <br /> . .. . <br /> White C4?�01 <br /> Yellow Copy:Operator Pink Copy:LEA 51A <br />