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p <br /> Waste Tire S y & Inspection Reporflnspection Report Number ■ <br /> State B California y 9 Il - 1088081 <br /> F CIWMB 181(New Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> ,Part-A--Survey - BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details - - - - -- <br /> TPID- inspection� � � � � Inspection Type (Fill one) <br /> Site Suffix: �-� f� ' `� �I Routine 0 Re-inspection 0 Referral 0 Observation <br /> l� <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: n ��Jt•1, 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address __j P) <br /> Street -- <br /> r �r I --IJ <br /> �` i is4lsInspection Date IF9 <br /> L. —_......_.__..�_ _._�.-.____._.��- — ! Time In Time Out <br /> City State Zip Cade ---,...._.....__ JT� <br /> -Business Rep Title 0 AMO AM <br /> 0 PM ® PM <br /> 04, <br /> r , <br /> Operational Status Tire Type Business Role Storage Type <br /> ( 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger Q Generator 0 Outdoor <br /> GPS �1D 0 Closed 0 Altered <br /> Latitude I I . 0 Hauler 0 Indoor <br /> Il—jp 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Busineso-Type (Fill all ilial apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility it ENFORCEMENT STATUS <br /> _._ <br /> V A HAULING,AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0, PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> IN, <br /> 0 0 ,PRC§42953-Contracts with Registered Waste Tire Haulers. 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 / m 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 14 CCR§18460.2-Manifest System RequirementsLogs for 3ears <br /> 0 O or 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 O In Compliance - No Violations <br /> 0 0 Other: § <br /> CommentsS(h - <br /> 1 <br /> Inspection Form Included 0 <br /> ,F' l"$! f <br /> w <br /> Comments. Included. 0; ` <br /> Business Rep's Signature Phone Number Inspector's Signature,, Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X Ak N/ , Off, D 2 <br /> � <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA: ® ■ <br />