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Waste Tire SL, ey & Inspection Repoli _ Inspection Report NumberState ■ <br /> CIWM f 81(New <br /> Survey Form Page 1 Il - 1127670 <br /> CIWMB 181(New nage) V y g <br /> California Integrated Waste Management Board `�' <br /> PartA- Survey --_ _- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection— © Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Localr1— If Referral,choose referral type(Fill one) <br /> Identifier: SCAO ` ►6 L(,L)LL,n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Vv l Inspected By Inspector <br /> Ph slca 1 Add1rQ l S t r v 1 �. — O 3 I <br /> ( &n EsCAD <br /> 3ao'D SUIA�) C� <br /> O L Y O CA 95.ao� Inspection Date ` <br /> Time In Time Out <br /> Bus�in�e)ssI Rep Title _ u O AMQ AM <br /> l/"1L ll�l 1i <br /> don(-(. f 1 �jj 02 4 ® PM a 5 PM <br /> ---- --— _ - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 9 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 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 0 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 <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 DateM / 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 1 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 <br /> Q Q Other: § in Compliance - No Violations <br /> I <br /> Comments Qoi 1 �n5 OA - I' g - - C{ C�G11f1U V�1 II 1 t <br /> _ a owe <br /> I <br /> ,Inspection Form Included: 01 <br /> Comments Included:. — -- -- - <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect /! E A M T t�� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE ■ <br />