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Inspection Report Number <br /> Waste TireOwy & Inspection Rep p p <br /> CIWMB181fornia <br /> (New 04104) I 1 - 112 7 7 0 L <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 ,� � I � � _ O � Inspection Type (Fill one) <br /> L <br /> Site Suffix: O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SC�>n Jo L'Jr) �1.UY) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> C � Inspected By Inspector <br /> J u <br /> Physical Address J ✓ V ( ,�(Cn CS <br /> N I,+n S- . <br /> C L(/� Inspection Date f O I <br /> Time In Time Out <br /> Business Rep Title 0AM s 0 AM <br /> f <br /> 3 I 0 0 PM S �J O 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 /> 0 Active 0 Passenger Q Generator ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use I Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> • Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <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 /> Q Q 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1 i <br /> Qt, ane 115( nn �cl' r.cl%l�l--�n ��S 41h,—�li1U�`l' �b1�11~nSc� --- <br /> -t�lokz ' 1. �acil� P � �'►rte �5� �_L_;� ��_�zts � -ire, uull� - <br /> Inspection Form Included: 01 o R <br /> s7s <br /> Comments Included: Q ---�Si; <br /> sines, s Si ature Phone Number Inspece Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect I E A My E 112 3 62081 <br /> _ _ X � --- <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop(LE ® ■ <br />