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Waste Tire sty & Inspection Repo" Inspection Report Number <br /> A <br /> State of CaliforniaClWT ■ <br /> California Integrated 1Wast81 e Management Board Survey Form - Page 1 1 114 0 7 4 7 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1A � I _ � 1 Inspection Type (Fill one) <br /> Site Suffix: ! 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^ Cru 0 CHP 0 CIWMB. 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _— -- _-— - - -- -- <br /> T` ) Inspected By Inspector <br /> Physical Addir s �P��ul C� - - I V �St0-O <br /> 1-��- <br /> Inspection Date Q j '7 / I O <br /> -� sCkD� c�, <br /> Time In Time Out <br /> Business Rep Title Q_ O AM U O AM <br /> �U amu^^ �S111a ILtt ® PM 1 PM <br /> --- - Operational Status Tire Type j 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 /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered 1 <br /> GPS Latitude NI� 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Lf <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder Other �f 4�5TQ7 S�a d� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 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 I PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 i 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 EXT) <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 • In Compliance - No Violations <br /> 0 0 (Other: § L7 <br /> Comments �` ,� �l f ` �_„ { fl <br /> a,S e, 1 �1 `mow t?�.- T — <br /> Sr0`�c�y�� <br /> Inspection Form Included: 01 2 a _ <br /> I Comments Included: *1-- -- - --- <br /> Busin _ Signal re Phone Number Inspec s Signature hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE ® ■ <br />