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Waste Tire Su. :y & Inspection Repor� Inspection Report Number ■ <br /> FIi State of California 11 - 1127690 <br /> CIWMB 181 04104) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L, 0 5 'q - O ` o Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local //� ,� If Referral,choose referral type(Fill one) <br /> Identifier: C��� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> U0 }e n — A <br /> Phys al Address <br /> l O �!}lI <br /> 1050 60. <br /> 1 l� <br /> Gr _ �I Inspection Date <br /> Df��' Time In Time Out <br /> Business Rep TitleO AM O AM <br /> M1��,�,�G � C) � ® PM �PM <br /> O - - - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — ®OTR End-Use ® Container <br /> 0 Planned <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN RCEMENT STATUS <br /> �V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 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 <br /> m / 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 <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 <br /> ® In Compliance - No Violations <br /> Q 1 0 Other: § <br /> Comments 021 <br /> do 4z>lcchZw cr _-) o rcca,�rl <br /> Inspection Form Included: 0 �4Wr _70.. <br /> I Comments Included: 0 J _ . </z 7S <br /> L_ Busi ess R p s Signature_ Phone Numbers I is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: \/! X A p L F 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: ® 0 <br />