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Waste Tire SL_ ✓ey & Inspection Repos Inspection Report Number <br /> 1eH State of California 11 - 1127717 <br /> CIWMB 181(New <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Pant A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /-S _ Inspection OTypeonp O O <br /> Site Suffix: c/ I6 �1 Routine <br /> 40 Re-inspection Re-inssection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> picczrf-:�\ <br /> PhyslcalJAddress 3 cl � l /I-{�.1m 1'k <br /> M;m Avg �'- <br /> 1, <br /> 5a Inspection Date I 7 0 <br /> Time In L� Time Out �J <br /> Business Rep Title 0 AM O AM <br /> vl� - �-® PM ® PM <br /> hum/y�IE. «Z � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> _ 6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — End-Use Q Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q 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 ENFORCEMENT STATUS _ <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 0 Other: § <br /> Comments <br /> Inspection Form Included: Q� , , 1 �} <br /> Comments Included: Q <br /> Phone Number I_ t s Si nature Phone Number <br /> INSTRUCTIONS ON BACK C erro ct:9 Incorrect: i 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: ® ■ <br />