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inspection Report Number <br /> Waste Tire-z"Wil ,,ey & Inspection Rep(.,, <br /> •��� State of California 1' ' <br /> CgWMB rated 1 teManage Survey '�.ari-vi - Page 1 I 1 - 1140934 <br /> California Integrated Waste Management Board <br /> Part A-Survey - - - - __ BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- ` n _ ,�91 I Inspection Type (Fill one) <br /> Site Suffix: 1 0.J U Routine <br /> Q Re-inspection p Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) - - <br /> Identifier: <br /> 0111 ( { jj Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t J{ Inspected B <br /> P Y Inspector <br /> Physical Address <br /> (�b (A Inspection Date <br /> UI'�Lyt�, I J t a Time In Time Out <br /> Business Rep TitleOAM <br /> 1 1 ` 4 P 41AM <br /> C�n la,i✓�L, �G�e-�j�- j GC�Uhe r . PM <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ �Active Passenger Generator <br /> � Passen 9 � Q Outdoor <br /> Latitude O Q Closed Altered CPS 0 Inactive Truck 4P Hauler Q Indoor <br /> Longitude Q Planned ® OTR Q 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 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 ® Hauler Q Agriculture Shredder Other 1 <br /> Q s ��T,u�'f�t� ���11�'Un � <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A JHAULING 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 <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 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 /> - --- --- - <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 /> - <br /> Ov��n WG1,S o U1 ' <br /> --- <br /> Inspection Form Included: Q <br /> Comments Included: *Inspw�ct <br /> Business Rep's Signature Phone Number Signature Phone Number. <br /> INSTRUCTIONS ON BACK I Correct Incorrect 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: EA . <br />