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_ pection Report Number <br /> Waste Tire Su4e & Inspection Report � <br /> ■ ,,, State of California I 1 - 1140730 <br /> CIWMB181 <br /> asteMana a Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � � � _� _ � � Inspection Type (Fill oneP O O <br /> Site Suffix: O <br /> Routine Re-inspection Referral Observation <br /> Local ��� /. If Referral,choose referral type(Fill one) <br /> Identifier: J((�C�.A �1` C C{�cJ1� -�/uviv 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ecxwl P©Wo,- cLar-VNLI�+-- a <br /> Physical Address J� U <br /> Inspection Date <br /> f-lccy\' C . C X 33"7 <br /> Time In Time Out <br /> Business Rep Title I ,Z L 0 AMt � �-7 0 AM <br /> Q ! PM ! 7� ! ® PM <br /> — -- - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _Tire Count(Whole/PTE)- - <br /> 0 Active ---0—Passenger ®Generator 0 Outdoor- <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> t J <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other /-Z)Y l l/ ��'Se✓1�2C��'��' <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> V0 PRC§ - 0 Notice Of Violation 0 Extension <br /> 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> g' � Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 0 1 0 Other: <br /> § <br /> Comments 1'wVll►!� �'1f� ��1� �1La Vy7>�Cvfj-�rl J COY 17Y�1rj ��1� <br /> l� l l o S11C�--------- <br /> {/// (/ v�._ SSP-p 1 Wiz; i�c1��S-=- -�rrevt,�'f � � 'if�___C'o r►1Pcc h �✓�` =- <br /> ( <br /> 1.36 iii .7. <br /> Inspection Form Included: 0: L <br /> Comments Included0 <br /> : A CL► o- �t'�`' <br /> ,Business Rep's Signaaaature Phone Number I C r' ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X + �/ _Xj A P! 11 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L LJ ® ■ <br />