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a <br /> Waste Tire SL yy & Inspection Repor� Inspection Report Number <br /> State of CaliforniaClWMB 181 eIl - 1140896 <br /> California Int grat dWas eManagement Board Survey Form - Page 1 <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: ( 2 9 `1 '2 � 3 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cj �ni..�n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName QQ Inspected By Inspector <br /> �.y / <br /> Physical Address %�/ — ` 1 erVHC�V`, <br /> 3 3 1- Gert_, Z11121 - - <br /> Inspection Date A / I O <br /> Time In Time Out <br /> Business Rep TitleO AM !/ i0 AM <br /> l S ® PM l 2 T� U ® PM <br /> - erational Status Tire Type Business Role Storage Type <br /> i <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �-f- <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <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 /> 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 /> I <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments 1/1,17 /• f _ �' <br /> Inspection Form Included: Q y <br /> Comments Included: ® --- --- --- -- - --------�z � 62-- <br /> Business ep's 'gna a hone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correc :O Incorr t: X I E X A M�. 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co V <br /> © 0 <br />