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Waste Tireu y & Inspection Repo"Inspection Report Number <br /> State B California I 1 - 1143811 <br /> CIWMB181(New nage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- 1 l © ( Inspection Type (Fill one) <br /> Site Suffix: ` a 5 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local s ` If Referral,choose referral type(Fill one) <br /> Identifier: S(,t o � u�(\ �U,f\ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 3 9 ) t✓n C � <br /> Physical Address - I ( I � C CO <br /> S'so(�a.v�� CA �)6 Inspection Date � � � � / I <br /> Time In Time Out <br /> Business Rep Title + AM l U 0 AM <br /> ` <br /> 00 QPM 1 ` 0 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive � Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned OTR <br /> Business Type (Fill all that apply) ------ <br /> p New Tire Dealer p Auto Repair p Trucking Fleet Government p Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 6 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q HAULING AND MANIFEST REQUIREMENTS <br /> 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 O ---- - - <br /> 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 Other: § __—_--- <br /> Comments Ify*- .�1 r) f%— TG1�mR arl S Ol c c. ,rrti�r�r of WU y — <br /> N 0� Fu, t- "ayciu <br /> Inspection Form �nc <br /> ncluded: Q 54 Dub <br /> o10� <br /> Comments luded: --- C, s S <br /> Business Rep's Signature Phone Numb_e_r -Inspe iignature __ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Er A M 1. E 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink CopVIEA ® ■. <br />