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Waste Tire Mey & Inspection Repoli L Inspection Report Number <br /> ■ rLP ■ <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1143825 <br /> California Integrated Waste Management Board <br /> Part A- Survey__ - BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: U U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: Sal) 40CLI.— <br /> EW-skness LU I, bUlnT <br /> C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> esorLFacility <br /> lName Inspected By Inspector <br /> Physical Address 1 n 6544 <br /> Inspection Date 1 � (� � / �L /1 V <br /> Time In Time Out <br /> Business Rep Title 0 O AM L� Q AM <br /> ' O �/ ® PM 1 5 0 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 /> A Active Q Passenger ® Generator Q Outdoor <br /> - --------------- ~— - -- ---0-- Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) FprLr { <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 m / 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 p 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 <br /> In Compliance - No Violations <br /> Q Q Other: § 1 1 <br /> Comments PCAQS f�Q(4 � 11 n W�` <br /> 1 --- <br /> Ins eComme is Included: Z (r ' <br /> Inspection OF <br /> -/�1 - 1�Y �O� <br /> - -&'signature - ung-3l�6 <br /> Buslness R Phone Number Inspect gnat re hone Number <br /> INSTRUCTIONS ON BACK f Correct Incorrect r ,+ E X A P` � t 1 2 3 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ® 0 <br />