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Waste Tire Sum Inspection Report Siaction Report Number <br /> Statef California <br /> CIWMB <br /> 04104) <br /> I 1 - 1127524 <br /> California Inegrat dfWas eeManagement Board Survey Form - Page 1 <br /> in A- Survey BLUE OR BLACK INK PEN <br /> usiness Profile i Inspection Details <br /> PID- I � ~� � � ('`a � - � t �Inspection Type (Fill one) <br /> Site Suffix: ( '"� I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC � v `� If Referral,choose referral type(Fill one) <br /> �� <br /> Identifier: J �V /+ � I0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> C4LJ_Mms�> UP <br /> Physical Address 3 - <br /> � - m6,�� Azc.tnbJk <br /> ^� � Inspection DateV1 cic&_ <br /> I Time In Time Out <br /> Business Rep Title <br /> ` \p Title / 1 �./� O AM : 3 0 AM <br /> �{1UY1C C) rerr ICJ�y)) ES l7e ez- \ ' 4CJ -� � ® PM �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 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 10 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 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other Uf� e- C <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 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 0 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 EXT) <br /> 0 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 /> O0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 <br /> , <br /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 Other: § <br /> Comments <br /> 150 <br /> Inspection Form Included: 0 r� ( /1 Q <br /> Comments Included: - -- - -- - - . - -- - Kigi <br /> 7� G 7R V <br /> siness Rep's Signature Phone Number I tor' urePhone Number <br /> ---- - - — <br /> rt -- - -- - - <br /> INSTRUCTIONS ON BACK Corr W�frQtr@Gs q °, a, , 62081 <br /> White Copy: IWMWM Yellow Copy:Operator Pink Copy:LEA <br />