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=fi $ Waste Tire Sui y & Inspection Report inspection Report Number <br /> State of CaliforniaCIWMB 181 04104) <br /> T 1 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 I y 1140693 <br /> Part A- Survey_ BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID --- J --- _ O / Inspection Type (Fill one) <br /> Site Suffix: — 5 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�wl ;„ / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '�� -- - — - - — <br /> Inspected By Inspector <br /> ProyX'+o's <br /> Physical Address 3 �� - O <br /> Locc CN >-y o <br /> Inspection Date C) <br /> qs <br /> Time In Time Out <br /> Business Rep Title / 0 AM O O PM . <br /> ® PM Q AM <br /> � � I S <br /> Po4ro PAfAl(fC Z r - - - -- . <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 /> ® Active ® Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitudel Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTRQ End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 HAULING AND MANIFEST REQUIREMENTS <br /> - ........._.._. _... . �__.._ _— _._._._ _. _._._` . _ .....1 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 m / 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 EXT) <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 1 Other: § <br /> Comments <br /> R i►-,r��*;�,r.. <br /> Inspection Form Included: Q <br /> � �-- a <br /> Comments Included: ® - - - - �- <br /> - Busine ep's nafure Pho ber ns�Sl�ature Phone Number <br /> INSTRUCTIONS ON BA Corr c : ncorrect: AAWLIE1 2131 62081 <br /> White Copy: IW B Yellow Copy:Operator Pink Copy:LEA <br />