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Waste Tire bu. fey & Inspection RepG. L Inspection Report Number ■ <br /> E3I9 CIWMB 81California <br /> CIWMB survey Form - Pa�uye 1 I 1 1143798 <br /> california Integrated Waste Management Board ! J <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral O Observation <br /> Local l 1 If Referral,choose referral type(Fill one) <br /> Identifier: Sup hoc wl n COUA �1 Q CHP 0 CIWMB Q Complaint Q Educational Visit 0 Other <br /> - - J <br /> Business or Facility Name <br /> `' 1 Inspected By Inspector <br /> tkoi�' bk Fcti'tiT i c5� SCS c ( _ <br /> Physical Address 3 1 _ <br /> Sir �� Inspection Date <br /> O � / 1 <br /> Time In Time Out <br /> Business Rep Title ` O 5, 19 AM Z AM <br /> (An � {15 � � -1-�-- -- nal -- Q- <br /> -PM — <br /> � O PM <br /> O eratioStatus (ire TYPe Business RolleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) Fill all that apply) Fill all that apply) (Fill all that app <br /> l <br /> y) <br /> 9 <br /> * Active Q Passenger O Generator Q Outdoor <br /> Latitude Q Closed Q Altered A <br /> GPS Q Hauler O Indoor <br /> b Q Inactive Q Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 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 ShredderOther p ,�� <br /> >S <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O Q 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 <br /> m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - - - - - - - - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators #In Compliance - No Violations <br /> O O !,Other: § _ <br /> Comments <br /> J-- <br /> .Uo <br /> su. oAlil �i -vIc nl�l tcmC4w . <br /> Form Included: <br /> Inspection "-,gnat _ 3 17S <br /> Comments Included: <br /> Rep' <br /> ne Igna ure Phone Number Phone Number <br /> 112131 62081 <br /> INSTRUCTIONS ON BAC Correct: Incorrect: /: k A iT <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py:L ® ■ <br />