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ii__.A <br /> . Waste Tire SL1 :y & Inspection Reporit Inspection Report Number <br /> F <br /> State of California <br /> CIWMB181 <br /> Waste <br /> eManage) Survey. Form - Page 1 Il - 1140766 <br /> California Integrated Waste Management Board <br /> Part A- S_urvey BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection 1 Inspection Type (Fill one) <br /> Site Suffix: J _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �,y�, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> -- - - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - 3 <br /> ��'r+G� / rGf/1'7Ci•% fJl(�Y/(� <br /> Inspection Date <br /> S tv c�c-�,� G� 9s�vs� <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> 1 V ® PM ®PM <br /> Operational 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 /> 1C� 9 Active 0 Passenger ® Generator ® Outdoor <br /> 0 0 Closed I 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive ® Truck I <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> - I <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 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 /> 0 ! 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 010 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 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 /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers li 0 Referred/CIWMB Enforcement <br /> 00 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> - .. _ <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations j <br /> 0 <br /> (Other: § ® p _ <br /> Comments <br /> /�!/1.c./rte• �n t •�, -��s G�Cc�e- c�� 1���� <br /> Inspection Form Included: O1 <br /> _7 <br /> Comments Included: - --- - - -- - <br /> ® Business Rep's Signature Phon r nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK i Correct:`, Incorrect.XJ A 1 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop ly <br />