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? Inspection Report Number <br /> ® . Waste Tire SuAly & Inspection Report - <br /> 6U1iI State of California Il - 1088073 <br /> CIWMB181(New04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board — ---- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- qle � <br /> Inspection Type (Fill one) <br /> Site Suffix �l1 ` - � 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: i �LfrL t' , tLl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> IPhysical Address �`^-� , <br /> Street <br /> Inspection Date <br /> —� <br /> State ZIP CodeTime In Time Out <br /> _. <br /> Business Rep -•Title 7 0 AM -- <br /> [.. _ O AM <br /> C I - -- .. LT <br /> 0 PM _ 0 PM <br /> Val <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 /> (k) Active 0 Passenger 0 Generator 0 Outdoor <br /> J—] <br /> 0 0 Closed 0 Altered I <br /> GPS Latitude ( 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - ...r._.�.,--.. 0 0 End-Use 0 Container <br /> 9� 0 Planned 0 OTR <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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <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 li PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / 7 <br /> 0 0 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 - -- - <br /> 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 J 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 0 In Compliance No Violations <br /> 0 0 Other: § - - -- - ---... <br /> Comments <br /> �f- E 6 <br /> inspection Form Included: 0 <br /> 0Comments Included: <br /> BUsinesRe 's Signdadlae Phone Number Inspet_t.os ,,. ..-. <br /> (._ <br /> Signature Phone Number <br /> .. 62081 <br /> INSTRUCTIONS ON BACK Carred:® Incorrect: X ;> l 12131 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LE <br /> i <br />