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® spection Report Number <br /> Waste Tire Su� & Inspection Reportt <br /> State of California T 1 - 1088373 <br /> CIWMB Form Page 11 - <br /> California Integrated Waste Management Board <br /> - _ <br /> BLUE OR BLACK INK PE <br /> Part A- Survey <br /> Business Profile M Inspection Details <br /> ' _ - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: bl. V { t (�G t. i'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _/1 1 r Inspected By Inspector <br /> > r c�J, f :C J r•� ! (� / <br /> Physical Address �?� .,_..._� .�.� y ' fit I: rGl <br /> St,-eet <br /> _ Inspection Date / t f^-- �+ �" / Foa <br /> City -- -- State ZIP Code Time In Time Out <br /> Business Rep. Title 0 AM <br /> 1 0 PM y ( �J 0 PM <br /> Operational <br /> I Status iTire <br /> aYP <br /> Business <br /> ole Storage <br /> eTa <br /> ( oneonly) (FII all that apply) ( ll all that apply) alply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude ,f i � � Q Hauler Q Indoor <br /> ,ill----LLLLLL <br /> Q Inactive Q Truck <br /> ude 77-11 <br /> o End Use Q Container <br /> �Longit <br /> Business Type (rill all Thal apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 HAULING AND MANIFEST REQUIREMENTS o Notice Of Violation Q Extension <br /> o o PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> § <br /> OO 42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> , I PRC <br /> 0 1 o PRC§42956-Registration/Decal in Vehicle <br /> 0 1 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> o O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 1 o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> olo § _ <br /> 0 o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators o In Compliance - No Violations <br /> o Other § <br /> - <br /> Comments <br /> C ��{ ✓ ( <br /> J <br /> Inspection Form Included: Q, <br /> Phone Number Ins actors is nature Phone <br /> Comments Included: o'',Business Rep's Signature Phot � :„ m <br /> ^ p -- �,g Number ' <br /> P` g - — <br /> C�_ 62081 <br /> 112 '3 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X LE A <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />