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® Waste Tire SL ay & Inspection Repor. Inspection Report Number <br /> CIWMB;1'fornia <br /> (New04104) Survey Form - Page 1 1 8 - 1 0 Q 8 i 2 1 <br /> California Integrated Waste Management Board <br /> Part A- BLUE OR BLACK INK_ PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , l7 ` Q Routine Q Re-inspection Q Referral - Q Observation <br /> Local p(� If Referral,choose referral type(Fill one) <br /> Identifier: S CIA ,O Cc � `,p�•�1q/ Q CHP O CIWMB Q Complaint 0 Educational Visit Q Other <br /> - -- - U- -- 1 — - - - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address LL <br /> �- <br /> 1N �� <br /> Inspection Date / D� 0�� <br /> -c.-c S 3L <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 4 O PM <br /> - - Ww � Operational Status Tire Type <br /> - Business Role <br /> Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> p � <br /> 1 - 'Active Q Passenger Q Generator Q Outdoor <br /> 0 ® Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use _Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler 0 Agriculture Q Shredder ® Other ,�v <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - -...-----—--------- — — - --- — - ---- - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Q Notice Of Violation Q Extension <br /> O <br /> 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 /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> ,- <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> -- �3�•.r'oll� �-�,�_►Z o4�d.�. �cn.� -�N t7 _v�-�c�5� ���t.,�� -P�.��'c- o�_Q�e�r�c,_1�+� <br /> -C -.�PxS - fly r`�__ .`.'VU AAi'w� - <br /> f�• <br /> Inspection Form Included: 0 <br /> Comments Included: - - - - <br /> - Business Rep' ignature Phone Number Ins ector's Signature Phone Number J <br /> INSTRUCTIONS ON BACK Correct. Incorrect:X+ ( i EX A;NI P; 11 <br /> 1 2 3 62081 <br /> �_� -- - -- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />