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Waste Tire Su, _ ay & Inspection Repo* Inspection Report Number <br /> ■ Yi7 State of CaliforniaCOMB 181 04104) <br /> T ■ <br /> California Integrated Was eeManagement Board Survey Form - Page 1 I 1 114 3 9 51 <br /> Business Profile _ — _ Inspection Details BLUE OR BLACK INK-PEN f <br /> TPID- v\ Inspection Type (Fill one) <br /> ffii <br /> Site Suffix: 1•�1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �— 1 If Referral,choose referral type(Fill one) <br /> Identifier: CA l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> M C_cc) �t u t�C, 7� r�. �es V�I',Q_, G��c r 3 <br /> Physical Addr sq5 0,kS �S«,{. 0 <br /> Inspection Date O I <br /> I Time In Time Out <br /> Business Rep Title (D AM * AM <br /> c1- l\/I O PM I O PM <br /> – -- --- — – – - ––--– Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � ?j <br /> A Active Q Passenger le Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler ® Indoor <br /> O Q Inactive #j Truck <br /> LongitudeQ– Planned Q OTR End-Use Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j ENFORCEMENT STATUS <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q § 9� P <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 / m <br /> Q 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 �e- 1fC�— 5 �_( IfW, CIA C_ <br /> Inspection Form Included:Comments Included: ® v <br /> �2 ��f�f6�fsS�l �� � <br /> oq <br /> ®�Business Rep's Signature Phone Number Inspec r s Ignature hone Number <br /> INSTRUCTIONS O - - - - _ ---- - <br /> N BACK Correct: Incorrect Ir j( A JI P' L I 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />