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Waste Tire SL_ ✓ey & Inspection Repor, Inspection Report Number ■ <br /> State of CaliforniaClWMB 181 I 1w 0410 - 1127878 <br /> California Integrated Waste eManagement Board Survey Form - Page 1 <br /> PartA- Sum-- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' ./ O tQ t Routine Q Re-inspection Q Referral Q Observation <br /> Local �� ^ If Referral,choose referral type(Fill one) <br /> Identifier: ��� l��iJl Lj Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (( Inspected By Inspector <br /> Physical ddress l 0 1 416,-, �K� <br /> ]- <br /> �5 f etre lAi t�- ' - <br /> CA cM�tQ� Inspection Date <br /> Time In Time Out <br /> Business Rep Title rr Q O AM �-S Q AM <br /> l 0 0 PM V 0 PM <br /> l --- �Kra- ' Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) '3 C) <br /> Active ® Passenger .Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned 00 TR Q End-Use Q Container <br /> - <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 FENFORCEMENT STATUS <br /> _V7A I HAULING AND MANIFEST REQUIREMENTS <br /> Q QQ Notice Of Violation Q Extension <br /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 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 /> QQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q � In Compliance - No Violations <br /> Other: § <br /> Comments <br /> Aori <br /> Inspection Form Included: Q <br /> Comments Included: — -- -- — <br /> Bus! ess Rep's Signature Phone Number Alnsor'sAij(nature Phone Number <br /> INSTRUCTIONS ON BACK Crrect:* Incorrect: 2 3 62081 <br /> _ X .1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.-4-111" <br /> opy: ® ■ <br />