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e . Inspection Report Number <br /> Waste Tire Su y & Inspection Repor. <br /> State of California <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 1 3 - 1 0 7 2 8 7 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 O �-li / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: SA� ��Agt-c�-)ej l^"�4-A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> CCATAAq Va(i-e� WA-ST-f- S>G2v�Gas q <br /> Physical Address au <br /> X333 5 . r<.j <br /> Lo d t' 952 I Inspection Dated q � -2 <br /> J G`' Time In Time Out <br /> Business Rep I Title 0 AM 0 AM <br /> NI IK�i A�G �.J s - - O PM O PM <br /> - - - � � � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 i/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r t 7 0 Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive i Truck <br /> Longitude - Q Planned • OTR Q End-Use • 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 <br /> Part B Inspection of Waste <br /> Was Ia Dealer,xGene gator, Hauler End-Use Facility ENFORCEMENT ST <br /> q <br /> va-gS Q Notice Of ViolatioxtehsonO <br /> 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 /> 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 /> - _ -- -- :. <br /> Q O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance <br /> Q 1 Q Other: § '� <br /> Comments <br /> /POUT%nlJ_ /�J,3 GLODAI OYJ WeS %�G //ouJ/''V� Gtl/}� J'T—d <br /> rAU,11 i;,-es •+s -Ihe-"A- t2-5,-,'_,S r ay d tip./44*41C4. A4A,y,i4sTJerl s <br /> Ill'--.j��-- -�SZ V,6 /A--TlynCt 0L 6NG��LS <br /> Inspection Form Included: Q 6P. 9 201 <br /> Comments Included: �l0 - ?y� 1/ �_ (4_� �68 16 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 1EjXjAjM.jPjLjEj1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />