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Ispection Report Number <br /> Waste Tire Su y & Inspection Report <br /> State CIWMB California I - 114 0 713 <br /> grated Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / y O / Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �'jr,W1 7�1C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> -- -- -- - <br /> Inspected By Inspector <br /> P"r,� y - D <br /> Physical Address ( / Awwid f Bocf'fiicvll <br /> Ade_. -- <br /> n O, Inspection Date <br /> Time In Time Out <br /> Business Rep Title 2(� 0 AM 0 AM <br /> pi/") `� I S • PM 0 0 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 /> 16 Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude iQ Hauler Q Indoor <br /> Longitude <br /> O Q Inactive Q Truck <br /> - <br /> 9 Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) ---' — <br /> Q New Tire Dealer Q Auto Repair p Trucking Fleet p Government p Retreader p 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 /> - —i HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Extension <br /> A --— --- <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 1 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 / FTI / 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 EXT) <br /> Q Q 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/CIWMB Enforcement <br /> Q O 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 Q,In Compliance No Violations <br /> Q Q § �� <br /> Other: <br /> Comments <br /> �u�f-i i,�_ Jn ry��'c�v �G,•�� c G�c�s�T lea E nPy <br /> rrrn <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> — - <br /> Business Rep's Signature Phone Number nsect <br /> por's Signature Phone Number <br /> -- - - e <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,� P 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: <br />