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Waste Tire Sub - *-�%y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181 I JL 114 0 7 8 6 <br /> California Int grat d Wast eManagement Board Survey Form - Page 1 <br /> Part A- Survey_ _ - —_ _ --_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 5 ' - © inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCLO 701 (6t, XI 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address {� ,, LAO <br /> c 153c� <br /> v, l Inspection Date 1 <br /> 1 `t Time In Time Out 1 <br /> Business Rep-- Title 10 AMQ AM <br /> 'DS\c- ��( � LDS OWrw, Q PM PM <br /> ill oneonly)Operational Status' Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` ( y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger 0 Generator 40 Outdoor <br /> O � I <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Hauler Q Indoor <br /> O 0 Inactive 0 Truck I <br /> Longitude – 0 Planned 0 OTR 0 End-Use 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 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer ID Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 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 j A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 m / m / m <br /> 0 40 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 EX7) <br /> 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 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 /> 1010 Other: § <br /> Comments fn' <br /> k 4 wcoAc <br /> 1 1 <br /> ��i_Le.-151'-UL� _lYi2rJt C)(� �CliS G, cy{ <br /> Was <br /> Inspection Form Included: 0 <br /> Comments Included: —\\�� y �-'" -- -- - ✓� /� ���—�Y1u�31��– <br /> ® Business Rep's Sign ure Phone Number YInspec s Signature – Phone Number. <br /> INSTRUCTIONS ON BACKCorrect: Incorrect i l { , h� p1112131s2081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />