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6><e. <br /> Waste Tire & Inspection Rep Inspection Report Number <br /> CIWMe 81(New04104) Surve Form - Page 1 Il - 1088076 <br /> California Integrated Waste Management Board y <br /> Part A-Survey _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , Ll Z O _ 0 Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �()an CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1�1v► Inspected By Inspector <br /> Qel Pd►b Oes - A o rn�J Ic` <br /> Physical Address <br /> 3$L,5 S. Et omx )o s1- <br /> Cc` �5a06 <br /> Inspection Date F O Z O <br /> lJ 1 <br /> Time In Time Out <br /> Business Rep '\ I TitledQ AM O AM <br /> OPM �-- L $5_ o PM <br /> J - 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 Q Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive I& Truck Longitude - Q End Use Q Container <br /> Q Planned Q OTR <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS__4117 <br /> A HAULING AND MANIFESI1EQUIREMENTS Q Notice Of Violation Q Extension 'I <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m m m <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q <br /> Q Q 14 CCR 18459.3-Retention of Comprehensive roe 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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q # In Compliance - No Violations <br /> O O Other: § - -- <br /> Comments <br /> ttm�nVico _ �cgS�la� <br /> �rax ®r171 .� le�-Tr � x�1� -�'1�1r Ct�le, -t-MEs s ,��o � 1 J <br /> CTL <br /> Inspection Form Included: Q173,) <br /> Comments Included: Q� � ' <br /> usi ss Rep's2gna Phone Number Inspect is nat re Phone Number <br /> INSTRUCTIONS O CK X p L 3 62081 <br /> BA <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />