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s ` <br /> ■ = Waste Tire Sup . ay & Inspection Report inspection Report Number <br /> CIWMB 81'fornia(New 04104) Surve Form - Paige 1 I 1 - 1143661 <br /> California Integrated Waste Management Board y J <br /> Part A- Survey-- - BLUE OR BLACK INK PEN <br /> jBusiness Profile Inspection Details <br /> TPID- -7 Inspection Type (Fill one) <br /> Site Suffix: r j 7 7 / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n �� f� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address /3 <br /> 3333 A4­40L'��►4r >� -- - -- <br /> ,, ,� Inspection Date <br /> 5 © 7 I / <br /> A�L� Qs- 8 <br /> Time In Time Out <br /> Business Rep Title (*AM IIIIII AM <br /> 0 PM 0 PM <br /> k_ C' <br /> Operational Status Tire Type Business Role Storage Type <br /> -- <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply)j (Fill all that apply) (Fill all that apply) <br /> ®Active Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 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 ® 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 /> V I, A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 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 /> 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 EX7) <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments fs Gt�i!y t' c2 CLGie�� L�-y LC. >94CW <br /> �CLCf�i <br /> - v c t <br /> �' % �S �9'e acf <br /> Inspection Form Included: Qj ii2� -- -__- <br /> /� .l 20- <br /> vy <br /> Comments Included: ��- v-rte- 1�- �'�rlo - "- " - <br /> Q1�8us�p's Signature Phone Number Inspector's Signatuqf Phone Number <br /> INSTRUCTIONS ON BACK Correct e- Incorrect „ �/ 1 A P 62081 <br /> �_. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: � ■ <br />