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M jWaste Tire SLft & Inspection Reporf tspection Report Number <br /> State California I 1 - 1127861 <br /> CIWMB 181(New Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA- Survey_ BLUE OR BLACK INK PEN <br /> Business <br /> ess Profile ✓ 7 " Inspection Details <br /> Type (Fill one) <br /> 3 ----- --- - --- - <br /> Site Suffix: 3 I v L ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> , <br /> Identifier: �� -�7x( �� �QlQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical Address - 1 Q l <br /> 2L?� S_ <br /> _ Inspection Date 0 / <br /> �cq�3 � <br /> Time In Time Out <br /> Business Rep Title D Q Q AM O a S- Q AM <br /> Mr � +CI ® PM ® PM- <br /> i C3 �C� �Gt..a� MG.a-tCeG�.c�1r -- - - -- --- -- <br /> ---- — - - - - - !Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 Auto Repair Q Trucking Fleet Q Government Q Retreader <br /> Q Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 i ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> ----- Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 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 <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 /> I _ <br /> 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 � sut�r r <br /> Loo 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsmphanoViolations <br /> Q Other: § <br /> Comments _ <br /> -- _1i2S C✓1ti 1 `S <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number -Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK � Ov <br /> � ItC � �� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy. <br />