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Waste Tire SL ey & Inspection Repor_ Inspection Report Number ■ <br /> CIWMt.B <br /> f 81(New <br /> Survey Form Page 1 1 9 - 1 0 7 9 3 .10 <br /> CIWMB 161(New 04!04) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r r //''�� �1 I Inspection Type (Fill one) <br /> Site Suffix: / '�" V v ` ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L6G q_,, ►'1 p(.(,i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> sem.kV4 I <br /> Physical Address <br /> (/lay--- cJ <br /> Street Inspection Date <br /> City State ZIP Code <br /> Time In Time Out/ <br /> Business Rep Title OAM (� 2 O AM <br /> v J � � ® <br /> kas_t�__ 49-r--i ® PM PMOperational 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) �I <br /> ® Active ® Passenger 0 Generator Q Outdoor <br /> Latitude J10 <br /> ®Q Closed Altered <br /> GPS � I Q Hauler Q Indoor <br /> 171 <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use (0-Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> (D 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 I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive.Trip Logs within 90 days (Required for NOV or EXT) <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 ® In Compliance - No Violations <br /> Q Q1 Other: § <br /> Commentsy tt' i t e 'yLI c-�Q y\ l,l�� �� n ote s +" ,c fp I(oyj I <br /> ^ n <br /> �. l t^or 112I / C)t- ti✓'� Q�c S;oD S�-Y o ��T Ir t�S 1�/` �t/�• <br /> a (sr) 6-S 0 Jy4ck-s r6cd dote cc?.s foulC'e <br /> r.2 _, d b r/_ [A/ec� <br /> Inspection Form Included: Q <br /> Comments Included: 091,9 6 <br /> Business Rep's Signature Phone Number Inspector4Siature- Phone Number <br /> INSTRUCTIONS ON BACK orrec Incorrect: X (� I 62081 <br /> ■ � XAhAP L 0 1123 <br /> White C py:CA Yellow Copy:Operator Pink Copy:LEA ® ■ <br />