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TECS <br /> Waste Tire Su y & Inspection Report nspection Report Number <br /> lIG Slate of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140659 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 2 2 _ I Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �wr\ y\ C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> j Business or Facility Name <br /> Inspected By Inspector <br /> inn <br /> v10 S f e- 1 S cam- )kxAo9 - 1 D <br /> Physical Address <br /> 1o2- �E. W<_ 0_V"_k - Sfi • <br /> CA y�s.�© 1� <br /> Inspection Date 7;1 / <br /> Lam, <br /> Time In Time Out <br /> Business Rep Title _ 0 AM • AM <br /> C, © 0 P 3 QPM <br /> 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 (a Passenger ® Generator 10 Outdoor <br /> Altered <br /> o iQ Closed Q <br /> GPS Latitude Q Hauler 9 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR-- <br /> Q End Use Q Container <br /> Business Type (Fill all that apply) --- - <br /> Q New Tire Dealer ®Auto Repair Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA 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 I;m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 l� n Compliance = No Violations <br /> 0 Other: § <br /> Comments_ <br /> Inspection Form Included: QI X �Signaurq, y67RO6ZCommentsIncluded: --Business Re�Signature Phone Number nsPhone Number <br /> - -- - - - <br /> - __.___ .--_�___ 62081 <br /> INSTRUCTIONS ON BACK Correct a Incorrect X;`\�' y JFIE, C A 4 ' (. 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy:L <br />