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ii-A <br /> Waste Tire fey & Inspection Rep Inspection Report Number ■ <br /> State 13 California Form - Pauye 1 I 1 - 1127746 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey _-__ _ _ _ _ _ _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details, <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 0 D 0 L( , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: S0. ���� 1!CXJYI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address ` l F{. Av7 6ok <br /> Inspection Date j Q —7 I Ct <br /> /r n,Gi� CC",- 95S76 Time In 4� Time Out <br /> Business Rep Title O AM �j "� O AM <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 Passenger Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude - 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 O 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 /> 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 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 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 /> Q Q Other: <br /> Comments <br /> 117 <br /> Inspection Form Included: Q <br /> Comments Included: .— rl!q'14e- <br /> -//4 • - � <br /> — --- - - --- -- — <br /> si ss Rep's Signature Phone Number I P ct r' nature/ Phone Number <br /> ot <br /> INSTRUCTIONS ON BACK i Correct.* Incorrect XE A ", L 2 3 62081 <br /> - - <br /> ■ -- <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:L ■ <br />