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=- Waste Tire Su. . Wy & Inspection Report Inspection Report Number <br /> 77 - State of California <br /> C181( e ) <br /> California Integrated Waste Management BoardSurvey Form - Page 1 i o - I U U n r 3 o <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 q S Z t 4 Routine 0 Re-inspection 0 Referra Q <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S •D R G1 �n� ��L��-� 0 CHP 0 CIWMB 0 Complaint 0 Ec :a Tonal Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> t V- X-C'V. 7 L � <br /> Physical Address - <br /> b4�9 �.-. 'TY�Vwyy�t� l-V\ <br /> Inspection Date 7- U <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> V VIA PM o PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill a' ma:a cly) (Fill all that apply) <br /> 0 Active 0 Passenger 0 G_=n_=-E:3r 0 Outdoor <br /> O ®Closed 0 Altered <br /> GPS Latitude 0 Hau!e- 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantle- 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> ® 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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ---------------------- ----------------------------------- <br /> I0 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 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> �0_-0 Other: § <br /> Comments \ <br /> Ct/� 'r\,\ t L-L.i L L v(� <br /> �, �,,, ` ,t,�-,vc� (.c �,u-c �' ►�r,L <br /> w t9 <br /> Inspection Form Included: 0 t - <br /> Comments Included: 0 <br /> BusinesksSi, ture Phone Number In pector's Signature Phone Number <br /> — -- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E XA it�TP L'�F_ I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />