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Waste Tire SAby & Inspection Repor0 Inspection Report Number ■ <br /> State of California t3 ;� A n A <br /> California Integrated as eB 181eManagement Board Survey Form - Page 1 L` - i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: j i� " � Routine Q Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: C-> 1 l 4A9 <br /> LR I/J �� �ti/ j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> c <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> tom_ , AAA�JTLc <br /> Physichl Address -- <br /> � C � �� e �J��reef Inspection Date <br /> �.._ �,� ___-1.__T---,------,_..___,------.-----+:��_� Time In Time Ou_t, _ <br /> ritti ,date ZIP Code <br /> Business Rep Title O AM AM <br /> ii 1. ' LJ [IPM __Lj. ___ 0 PM <br /> Operational Status (ire Type Business Role Storage Type <br /> Fill one only) Fill all that app IY), Fill all that apply) <br /> Fill all that app IY) <br /> Tire Count (Whole/PTE) ( Q g <br /> Active 0 Passenger 4 Generator 0 Outdoor <br /> _-....._. O Hauler Indoor <br /> G PS Latitude 0 O 0 <br /> --_ __ 0 Inactive 0 Truck <br /> _ - p <br /> Close Altered <br /> �� T~ <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 container <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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- <br /> 0 ' 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 /> 00 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 /> ---------------- <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance,,-,No, Violations <br /> 0 0 Other: § _ <br /> Comments 77 <br /> I c (i5rt/ NIV/ t�cltlt Al4(*_ fc=t.-,04- niq <br /> 1 i�� r{.r s� f (.rj i 1 i Y� r! 4-� /`' 4 �f1��-r{ — �� P 44,1 <br /> X A <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> •" 62081 <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: I !,�' J- ]. [2 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />