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Waste Tire S ►y & Inspection Repo4elnspection Report Number <br /> i6I _ State California 1 - 1140993 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- I ` - O Inspection Type (Fill one) <br /> Site Suffix: / ! ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sew TC4.L' %V— C_� , •_ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U►� Inspected B <br /> P y Inspector <br /> WOOCA <br /> Physical �4ddressrXC_ 3 <br /> a 6 3 ZRCA. - <br /> Inspection Date / 0 7 <br /> rc`-j cA `? 376 V <br /> Time In Time Out <br /> Business Rep Title <br /> Q AM Q AM <br /> f5 <br /> T- 0 0 QPM 4 S SPM <br /> Operational Status Tire Type Business Role j Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ® Active 1 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered N`� <br /> (3pS Latitude _-_ 0 Hauler 1 0-'ndoor--- <br /> 0 ! 0 Inactive •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 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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS j <br /> V I A HAULING AND MANIFEST REQUIREMENTS .......... Q 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 / J <br /> mm m <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 I <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 /> 0 0 Other: § <br /> Comments <br /> - i Ou- YUL- �1'tC `CJ J 't'1 ► C�C t- - � 4 <br /> Inspection Form Included: 0 � 3Z 7 2 3 <br /> Comments Included: <br /> - Business Rep's Sign ture Phone Number nspector's Signatur Phone Number <br /> - -- - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X J ;' E X AA I 2 3 <br /> 62081 <br /> White C,_;py.CIA t.lu Yellow C,py Operator Pink Copy:LE M <br />