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Waste Tire S�.._f y & Inspection Repor Inspection Report Number ■ <br /> ". State of California <br /> CIWCalifornia Integrated WaB 181 Je Management Board Survey Form - Page 1 ' f ' <br /> Part A- SurveBLUE OR BLACK INK PEN <br /> 77 <br /> z . x <br /> Business Profile:`` Ittspection Details .' <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I I � 1- - i ) ' <br /> ® Routine 0 Re-inspection 0 Referral Q Observation <br /> Local j' -- - - - If Referral,choose referraltype(Fill one) <br /> Identifier: O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address r - II <br /> �� <br /> 1_ <br /> Street p H_ _�] / E C�_J / :02 <br /> } ` Inspection Date <br /> I 1 k }�- �, C -Ir-. <br /> t�. 1 I <br /> City State Zip Code Time In Time Out _ <br /> Business Rep Title Q AM Q AM <br /> �. O PM ED �J O 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 /> ' ' 6 Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude }} ++ f 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> O <br /> Longitude - Planned 0-0TR 0 End-Use 0 Container <br /> �.. <br /> Business Type (Fill all that apply)` <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet D 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 ENFORCEMENT STATUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 for NOV or EXT <br /> (Required ) it <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 1 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (E)In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments _ .1 <br /> t1 tom' GCl"�_.LL r�� . 1-uf� i... Q _ t — Cl C ,,�',fo,+t �'�r O I <br /> r <br /> RrrArl`cl Y). F1u<-k -T)r(- rA(I -�Irc>_ _Cryl Q ��- - <br /> 1 `ff <br /> �e'El* 11i`.N\ i'}[ �L` C� S flf^ C�_v","' ; _ ,: .. — t-i.-3- Y o 4'b*'if —� 1 `-o r - - <br /> m <br /> Inspection Form Included: 0' <br /> Comments Included: <br /> 0 Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X2 .= <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />