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Waste Tire SL. ,rey & Inspection Repor. Inspection Report Number ■ <br /> State CIWMB California I 1w 04104) - 114 3 8 4 2 <br /> California Int grat d Waste 181 eManagement Board Survey Form - Page 1 <br /> Part A- --_ -- __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPISite - - Inspection Type 0( R -insp Q Q <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> Local �� ���� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad ress 39 <br /> q 530te Inspection Date O 1 o <br /> .�� 1 <br /> / tGG/ <br /> ( Time In Time Out <br /> Business Rep ` Title O AM �j Q AM <br /> Gje,vl�E rr —1 Q ® PM-- -- `! --� 0)PM <br /> - - - " Operational Status Tire Type Business Role Storage Type <br /> i <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l <br /> fb Active Q Passenger 0 Generator 4j Outdoor <br /> Q Closed Q Altered i <br /> GPS Latitude Q Hauler 1 Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR I Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler,and End-Use Facility ENFORCEMENT STATUS <br /> ----- ---- - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 m / 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 EX7) <br /> 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 Q Referred 1 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 ® In Compliance - No Violations <br /> 1010 Other: § <br /> Comments <br /> nG o - -- - - --- - -- - <br /> A10 Arca--> 6(- 6:-;rn6C-1?q <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> � a,gnatur - Bd4 7.5 9f'/ . off<//,Y -7 <br /> Business Rep's - Phone Number ncto gnature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:9 Incorrect: , i ! A ` 3 s2081 <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pink C y:LE ® 0 <br />