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fib <br /> Waste Tire Sure& Inspection Report ection Report Number <br /> State B California Survey rve Form - Page 1 I I 1127534 <br /> CIWMB 181(New nage) V � Y y g <br /> California Integrated Waste Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C Inspection Type (Fill one) <br /> Site Suffix: J t ` 1 ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �,-,- If Referral,choose referral type(Fill one) <br /> Identifier: \ `,� (� C � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business <br /> ,o/r�Facility <br /> -�Name Inspected By Inspector <br /> Physical Address � � ` D i ����, /�J�f•-(,'��1. <br /> Inspection Date 0 �f <br /> Time In Time Out <br /> Business <br /> sspRep /- _`� Title /ry O AM 0 AM <br /> 1 VCL\t✓ WC.� �IY1 E�Ct�'�� © v PM - 40 <br /> - - — Operational Status' Tire Type Business Role Storage <br /> p YP 9 Type <br /> vvv (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count Whole/PTE J 0 Active 0 Passenger ® Generator <br /> 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 Inactive 0 Truck <br /> Longitude 0Planned0 OTR 0 End-Use 0 Container <br /> I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ! / <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m m 0 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or 0(D <br /> 0 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 b r!t <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities x "P <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators InC I ance No Violatio s - <br /> Vit ,>v,a <br /> 0 0 § <br /> Other: <br /> Comments NL cm <br /> Inspection Form Included: 0 <br /> Comments Included: 0 esmess <br /> jSignatue <br /> - Wilgiture <br /> ep's Phone Number In_s c _ _ Phone Number <br /> INSTRUCTIONS ON BACK Cocorrect 62081 <br /> White CopyYellow Copy:Operator Pink Copy:LEA <br />