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Waste Tire Su ky & Inspection Report Inspection Report Number <br /> _= State California I 1 - 1140673 <br /> CIWMB 781( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> 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: O (� - © ® Routine Q Re-inspection Q Referral Q Observation <br /> R Local If Referral,choose referral type(Fill one) <br /> Identifier: � �e.,G2lJ1 a 1� �es wti Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (J Inspected By Inspector <br /> U (SLUMP U S Cw-t, <br /> Physical Address I a-,y+C ?1 a vl c 4- <br /> A14 R.vLcL4 ,E©e_V-44 ems. <br /> u3 - K �� . <br /> Inspection Date ( 3 f� 1 C <br /> S 1-o cac-w,-, C A a 5.21 ��'' ` <br /> cl <br /> Time In Time Out <br /> Business Rep TitleO AM 0 AM <br /> O <br /> j L 1 ® PM a d 0 P <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> f Q Active Q Passenger Q Generator 0 Outdoor <br /> O Closed Q Altered <br /> GPS Latitude Q Hauler ndoor - <br /> O QInactive Q Truck <br /> Longitude - Q Planned Q OTR 0 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 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> r <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> _-_ _—_ ___ __ __-__.. _ _.___.__ — :0 Notice Of Violation 0 Extension <br /> 0 0 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 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB j <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 1 Q Referred/CIWMB Enforcement <br /> 0 0 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 Q In Compliance - No Violations <br /> 0 Q Other: § <br /> Comments <br /> Y1 CPCC,(4 cw, 71A, f <br /> VAS (�'Lvs-ed. See PhoA-<�,s ckck-d 91lo(i o . <br /> c vrrn�n�v fD Gro s--e T-P//9 #. <br /> Inspection Form Included: 0 <br /> Comments Included: Q; - <br /> I_ Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X , X Liz] � 62081 <br /> 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pinkpy: <br />