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Inspection Report Number <br /> Waste Tire SuGey & Inspection Repor: <br /> StateCWMe 10181(New 04104of ) Survey Form - Page 1 1 4 - 1 0 2 8 8 41 <br /> New <br /> • Cal Ifornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 11 Inspection Type (Fill one) <br /> I Site Suffix: ` p U 3 1 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 1 \ \ Inspected By inspector <br /> Physical Address �cr�rcfdl�+~ Z-tl�y +:r <br /> t <br /> Inspection Date < 1 I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> /'a'` UL>`t_C..o-�•LLZ.t� pW�,Qi>� O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count{Whole7PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 10 Hauler Q Indoor <br /> O Q Inactive #Truck <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 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 ® Other Tii k-,- <br /> Part <br /> oPart B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A; HAULING ANDSMA NIFEST REQUIREMENTS <br /> --- -- ® Notice Of Violation Q Extension <br /> 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 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date I I r <br /> Q t Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from C1WMB <br /> 1 § 18459.2.1 -Submittal of Forms and Trip Logs within days (Required for NOV or EX7) <br /> Q 04 CCR Sblf Md TiLhi90 <br /> I <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q'Referred I CIWMB Enforcement <br /> I <br /> Q <br /> 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 COglpllsnce r No.Vlolations <br /> Q Q Other: § <br /> Comments <br /> oQQ <br /> o•.�'IC�,� '� t �(.. �>,5� -2.Lv-ta .c t3L SvyC'I,��� f <br /> Q Opo ,t?l��vt, 7l�t Sl SkC,L�_ ( \ l�0.t.Yi-� °V Y` ?.11A/ LS. <br /> l kA-)�ovv-&,C <br /> 1. <br /> Inspection Form Included: Q <br /> Comments Included: 0; <br /> I <br /> I Business Rep's Signature Phone Number Inspe tor's Signature" Phone Number <br /> INSTRUCTIONS ON BACK Coreecti.0 lnaorr+ ? Y) a t� L-� I j ] 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LFA <br />