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Waste Tire S4*.y & Inspection Repo, Inspection Report Number 81 ■ <br /> CIWMB California Form - Paae 1 I1 - 1127458 <br /> California Integrated Waste Management Board Y J <br /> Part A-Surve fes__ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �- l If Routine O Re-inspection O Referral Q Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: 60v l- 7,1 Q CHP -Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> ,1E�or�Facility Namee 1J I Inspected By Inspector <br /> in <br /> S, Y 1 er �IL�U��'.Ll ��1� <br /> Physical Address <br /> Inspection Date <br /> CSL `��`� Time In Time Out <br /> Business Rep Title ® AM l ®AM <br /> O PM 1 L� J O PM <br /> �- Pet(e_'1 i tr2 � <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 <br /> ' ' l ® Active Q Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive Truck <br /> Longitude — O Planned Q OTR I O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer; Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateIT / m / M <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators OVIn Compliance - No Violations <br /> 10 1 0 Other: <br /> :§ <br /> Comments f l��l�"'��P �tlYT Vt'✓�IX��'C� � T!'//.� �'' .�_ - -- - <br /> 1�'1G fyl/rG� oci cjce ' - <br /> '1� ,r - <br /> Inspection Form Included: Q <br /> Comments Included: Q -- <br /> Business ep's Signature Phone Number Ihspe i at re Phone Num er <br /> INSTRUCTIONS ON BACK �Correct:0 Incorrect: j V1 [y X I 41M I ir..Ve 1 111213 162081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink U/11 <br /> opy: ® ■ <br />