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Waste Tire Su 'y & Inspection Repor* Inspection Report Number <br /> i7. State of California <br /> CIWMB 187(New nage) u rve Form - Page 1 I 1 - 1141299 <br /> California Integrated Waste Management Board Y � _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile 11 I I"�i°�''" °��" 166Inspection Details <br /> -._ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i t 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �v� ` C�e li tT \ � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name- L Inspected By Inspector <br /> f If - <br /> Physicai Address �- <br /> r - <br /> ? - <br /> !eel I <br /> Inspection Date ( I G C <br /> City Slate ZIP Code I Time In Time Out <br /> � . � <br /> Business Re i ( _..._...... <br /> Rep Title I O AM i O AM <br /> ' QPM ' ! 0 PM <br /> _..___ w. <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholeE) =5 <br /> Q Active 0 Passenger Q Generator 0 Outdoor <br /> r — 0 <br /> ® Closed d Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> � '_ <br /> - - - Q Inactive Q Truck ' <br /> Longitude — O Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O 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 /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date M / m / m <br /> O 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 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 /> O Q 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 Q In Compliance - No Violations <br /> O 0 Other: § <br /> Comments <br /> -- - -=� . <br /> Inspection Form Included: Q <br /> Comments Included: o - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �, V AX,A, M' p � � 2�� 62081 <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />