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Waste Tire Efty & Inspection Repo Inspection Report Number ■ <br /> ■ '` I1 - 1140741 <br /> State of California <br /> CIWM8181(New041o4) 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: 1 d� "l -1 a 9 / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1l If Referral,choose referral type(Fill one) <br /> Identifier: / n 1 Q U�t� COlA o Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � 7•v� _ hh <br /> PhysicalAddrt�s 5 ' 31 I V ( &n CuOko <br /> local A. <br /> Inspection Date I I l V <br /> Loji CA ""0 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> a • O A PM 3 O 0 PM <br /> - -- - -- --- - -- - - Operational Status Tire Type Business Role Storage Type <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active Passenger 0 Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> QQ 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 / 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 Q 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 /> ,' t <br /> Comments �eU, 1012— �t,5 � ''�'� 1 n S(�c�"►o(1 �I�Orf�►�.(Jl 01�1 <br /> --- - <br /> Nib V, c7 �iO.AOf CA rn- <br /> (,Inspection Form Included: Q ��^ /,F /,� <br /> Comments Included: �I Al- !�� 5; a -'�" o U�3�7 0 <br /> siness Rep's Signature- Phone Number I�XA <br /> ct 's Signat one Number <br /> - --- -- ---- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i h t_ f i 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cy:L <br />