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- ' 0321703000Q <br /> W <br /> . <br /> Waste Tire-Sui ;y & Inspection Repor{ Inspection. Report Number <br /> 1d.. CIWStateM f 181(New <br /> Survey. - Pagel ..i 5 - 10 .1 . 3 7 2 3 <br /> CIWMB 181(New nage Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection w Inspection Type (Fill one) <br /> Site Suffix: O (a Routine Q Re-inspection Q Referral :Q Observation <br /> LocalIf Referral,choose referral type(Fill one), <br /> .Identifier: 65 Tom NIAJQL_� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Ins ected B <br /> P Y Inspector <br /> Physical Addr ss � L_�YN`""�. 1 / �'�-� � <br /> I )�0�I �S`, stac�n Et — - - <br /> Street <br /> /-I A- (3 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep Title (0 PM 10a 3 D j) PM <br /> ,Mar'CQ,�u�o �arrcl;lk ILE 4- -nUilfiT.r J <br /> Operational 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) <br /> ®-Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude <br /> O Q Closed Q Altered <br /> � . <br /> OH auler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — T] Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 17-r �^(��&r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ENFORCEMENT STAT_U_ S <br /> A HAULING AND MANIFEST REQUIREMENTS= 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 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> Q O -- - -- - <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 /> . 0 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No violations <br /> Q Q Other: § <br /> Comments <br /> cc;GL- c,�e s `Tb s ' rPtn# �o0(0J S 01-Q), ' f iy-'e &rVice q&-_t oSaQ� <br /> CTL S f fo r s V i ewed a%F ►ryV cfloT-t_i�1as <br /> v�o-1-M -f of T TJ D 1_�1 q a 0-of a� bee u sued Gi�S <br /> Inspection Form Included: Q 5001 <br /> Of <br /> Comments Included: ® / Puke408—q <br /> p <br /> NumberB si ss Signature PhoneNumber tor's Signature <br /> 62081 <br /> INSTRUCTIONS O BACK Correct: Incorrect: jEjXA P L E 102 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />