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s , Waste Tire Su, y & Inspection Report nspection Report Number <br /> �R State of California <br /> CIWMB181fst(New <br /> Manag) Survey Form - Page 1 11 - 1140869 <br /> California Integrated Waste Management Board <br /> Part A-Suive�r _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection z 1 - f� f Inspection Type (Fill one) <br /> Site Suffix: T V / ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �\ If Referral,choose referral type(Fill one) <br /> Identifier: C'" 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J V Inspected By Inspector <br /> X(ii /—P<-M S{„ ,,- <br /> Phyl Address '3 <br /> "1 - 1. 0 ' /tvr►cunr�4 <br /> 3 7 30 M va- ofd Ntt_ -_�k-- C <br /> Inspection Date c) � <br /> S+w C-k+ CA s7 i <br /> Time In Time Out <br /> Business Rep Title 0 ” 0 <br /> 0 AM <br /> �`�([ <br /> l Jas f�L-o. I"� ,C� 0 PM Q C� ® PM <br /> � v, 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 /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler • 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 ® 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 <br /> _ -....-...- —._._ ____._ _ __ - 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 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 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 I 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 /> 1010 1 Other: § <br /> Comments � � �,sl., <br /> Inspection Form Included: 0 <br /> Comments Included: ® -- - ---- <br /> o �b'�O 23 <br /> Business Rep's ignature Phone Number spector's Signat e . Phone Number <br /> _-- -- - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X , V r.X El 11 12n3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co A <br />