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c= Waste Tire SL y & Inspection Repor nspection Report Number <br /> EBG State of CIWMB 181 <br /> - 114 814 <br /> irZ S Cgrated Waste <br /> eManag) Survey Form - Page 1 11 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - -- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f y �j Q O Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �[crwy O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name77tZ '_ Inspected By Inspector <br /> Physical A dress <br /> r 70,90 - <br /> Inspection Date ` ` a v / Q <br /> Time In Time Out <br /> Businessl ep Title 0 AM r Q AM <br /> DC7 /CJ' 'ZGt.'Vt.r Lf"61 / eZ C� O ® PM ;2Y ® PM <br /> L 1G�9'IE< �rLC f`L 7't/ G rcc'f ro — <br /> erational 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 /> ®Active O Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive O Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 1 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> —__ ----___-._ -- -..-_ _- ____ . .--i Q Notice Of Violation Q Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 /> 0 0 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 /> 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 ® In Compliance No Violations <br /> 10 1 Q Other: § L --- <br /> Comments r- <br /> Inspection Form Included: Q <br /> 62-09) Y6 8 ��z3 <br /> Comments Includedr� . - - - -- -- <br /> Business Rep's Sign ure Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect: X ' ,' " e ? ',h� 1 3 <br /> White Copy CIWMB Yellow Copy:Operator Pink Co :L <br />