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r= Waste Tire Sr "3y & Inspection Repor Inspection Report Number <br /> C,WMBCalifornia( 04104) Su rve Form - Pa e 1 Il - 1143769 <br /> California Integrated Waste Management Board Y <br /> PartA- Survey__ ____________ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,�c� ® S Inspection Type (Fill one) <br /> V <br /> Site Suffix: 1 l 6 Routine Q Re-inspection 0 Referral Q Observation <br /> Local tet �/ If Referral,choose referral type(Fill one) <br /> Identifier: Sa,� UM (/l6A ►�IC, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> us <br /> Biness or Facility Name Inspected By Inspector <br /> d <br /> Physical A dresers <br /> 020.70 F <br /> Inspection Date <br /> � ��� Time In tX Time Out c <br /> Business <br /> ��Rep Title O AM 0 AM <br /> O PM � � � O • PM <br /> 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 /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 4p Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> a Used Tire Dealer 0 Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 40 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O1I O PRC§42956-Registration/Decal in Vehicle <br /> I I <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements 1 <br /> Date / '� / <br /> Ft <br /> O O 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 i <br /> (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included: QI i <br /> Comments Included: j - - - - / /_ ./ �� L�� C/ - - 1`16 -767 _ <br /> sl ep's-Signature Phone Number InT c is i natur Phone Number <br /> INSTRUCTIONS ON CK Correct: Incorrect: ; : �/� ! E 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE ® ■ <br />