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Waste Tire SuAU <br /> y & Inspection Report Inspection Report Number <br /> sgi� State of California <br /> CWM818' w /1 j. <br /> Ii(New04104) vey Form - Page 1 1 3 1 u 1 3 a o 0 <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: 6 Cj O i <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address <br /> �r�a�J� <br /> Inspection Date p� z / <:t / Q <br /> �J <br /> Time In Time Out <br /> Business Rep Title O AM { C O AM <br /> Z 0 5 * PM `J lJ PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger 0 Generator 46 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 19 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 /> HAULING AND MANIFEST REQUIREMENTS �$ <br /> — -- 0 Notice Of Violation 0 Extension�r <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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date m L__j <br /> Q O14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Rogtnred forNOV EXT) <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days � 4 <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred(CIWMB Enforcement $ <br /> �F <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators T <br /> ® InCompllance;F No Violations <br /> O Other: § <br /> O u <br /> 1 :c..Q <br /> Comments �_ _1�_r __- _ _ �� tq rn� <br /> o�r�(1 1 1�1`�IL 7') � ��- / /1 t_ ��L1Ll S�1(141.�./ <br /> t05"APS � '_ v C�,,l�� - Aol�" _s'535 415 Ilea re Com' c)-l!_� <br /> SOIL ctc-AP, � Vie. � -h-k f p_s 17'1.. n oa cs 'p� r i C'� :6( S5 l c 5 O <br /> Q5� y\ Y� �S� * ��-e(. it. <br /> Inspection Form Included: Q <br /> Comments Included: ® l` �/ ��1-07—L-1 141�1_ CQ 0 <br /> Business Rep's Signature Phone Number lnip4ctods 4ignature Phone Number <br /> INSTRUCTIONS ON BACK 1ENXIMIPILIE1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />