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- 111 Waste T; SL- ey & Inspection I <br /> "or'r� Inspection Report Number <br /> Ilida. State of California Il - 1127602 <br /> California Int grat d Waste CIWB 181 eManagement Board Survey Form - Page 1 <br /> Part A-S-urvey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - O Inspection Type (Fill one) <br /> Site Suffix: oq <br /> 46 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^,., If Referral,choose referral type(Fill one) <br /> `` <br /> Identifier: SLV1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector � <br /> Physical Address <br /> 773E E_ C ice Fe►� P,.S cL <br /> Inspection Date '� O <br /> � Kt Co.- g5aa6 l <br /> Time In Time Out <br /> Business R1epp, `f Title ` O AM �/ �/ 0 AM <br /> �� L1✓I�� "��C �S� L� 1 -. ® PM ' L C OPM <br /> - - - -- - - Operational Status Tire Type Business Role r Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �- <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 A _HAULING AND MANIFEST REQUIREMENTS <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires ONotice Qf Violation Extension <br /> 0 0 § g p <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. CompliarrGe D§e �lline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle 3 �' <br /> 5 �p <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> F <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a t <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 <br /> �" <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities ....................... <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators VW, ¢ <br /> ��tn��ptxp i�nc����p � l�tiohs� <br /> 0 0 Other: § <br /> CommentsA_Ui�fflf, - � <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> -Busin e ' ignature Phone Number Ins t 's gnature Phone Number <br /> — - <br /> 'r 16-14 NO i t 62081 <br /> INSTRUCTIONS ON BACK <br /> ogre � jX �`M F�E�l3l <br /> .� . <br /> White Copy:y:CIW CIWMB Yellow Copy:Operator Pink Copy:LEA <br />