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Waste Ti Mnspection R~- spection Report Number <br /> State I3 California 1 - 1143720 <br /> CIWMB 181(New Manage) 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- Inspection Type (Fill one) <br /> Site Suffix: 6 2 � -7 J � V � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � �" If Referral,choose referral type(Fill one) <br /> Identifier: ` <br /> sCiy\ J ',�t t XAq Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4� Inspected By Inspector <br /> Physical Address A "cr A <br /> Inspection Date � 1 C� <br /> _FfrAc1 6 A L1 <br /> Time In Time Out <br /> Business Rep Title ®AM ) ` ®AM <br /> L 0 O PM / ( c O PM <br /> Avy�lp_ <br /> — — t 1Gt1q'C- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active Q Passenger 0 Generator Q Outdoor Latitude 9 <br /> O Q Closed Q Altered /Yrf, <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive 16Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 0)Other ['tom n L.- -Sh 4-0 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> 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 /> 0 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 4( 'in <br /> Compliance - No Violations <br /> Q 1 Q Other: § �L <br /> Comments <br /> 7 <br /> Ac - - <br /> Inspection Form Included: Q <br /> Comments Included: --------------..._..__Z�S-—old <br /> Business Rep's Signature - Phone Number —In.-p- r s g ature Phone Number <br /> INSTRUCTIONS ON BACKKorrect.0 Incorrect: a/,i e X A M i �� E 1 3 62081 <br /> ® White Copy:CIWMB Yellow-Copy:Operator Pink Copy:LEA ■ <br />