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-;. Waste Tire Suil , y & Inspection Report Ispection Report Number <br /> PBGs+,i State of California <br /> ta:=m CIWMB 781(New 04104) Survey Form - Page 1 It - 1140861 <br /> California Integrated Waste Management Board <br /> PartA- Survey BLUE OR BLACK INK, PEN__ <br /> Business Profile _ Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: �O Z C) ® Routine Q Re-inspection Q Referral Q Observation <br /> Local > If Referral,choose referral type(Fill one) <br /> Identifier: ��(/►7 Q CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name, Inspected By Inspector <br /> Physical Address / Ly "'.4e, <br /> zY3-5-D <br /> _ Inspection Date <br /> �4&, tZ 1�:2l l 1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> .2I Y.CCi6- v� 00 <br /> 0 PM 0 a 7 u S ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> t J <br /> Tire Count (Whole/PTE) �+�j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active O Passenger Q Generator O Outdoor <br /> O 1& Closed O Altered <br /> RIS` Latitude --- - - - - - -0-Hauler-- - - <br /> v O Q Inactive p Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (it in Compliance No Violations <br /> Other: § ---- <br /> Comments �iy(.�7YLt, /�'!� ?/✓�- ,�t C �� ��.. '� .�i_i/fL.a - - <br /> Inspection Form Included: Q <br /> Comments Included: ® - �Lf mob 3 <br /> - - <br /> ess Rep's Signature Phone Number `inspector's Signature Phone Number <br /> _._.a ,,,,,,,,, .T- 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: X� , ,, �� ;C- X _� M � f 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />