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`=El3 Waste TireI*ey & Inspection Rep ' Inspection Report Number ■ <br /> State California Survey Form - Page 1 I 1 - 1127681 <br /> CIWMBB 181(New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q � Inspection Type (Fill one) <br /> Site Suffix: l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name p Inspected By Inspector <br /> ` Y 1 �W� n L/ z C <br /> Physical Address v 1 - D t , <br /> I 1` a'YA-'Voso, ')v. <br /> _ Inspection Date <br /> '�` ' <br /> "'v�� -.cc,,,- �� Time InTime Out <br /> Business Rep Title 4" O AM O AM <br /> L ' ' C ® PM I) WPM <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 /> IVE <br /> ®Active Q Passenger ® Generator ®Outdoor <br /> ---- -- - - ------- - - -- - 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned ® OTR <br /> Business Type (Fill alithat apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 J��U ✓I <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 <br /> 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 <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 - -- <br /> 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: § J <br /> Comments RL4ine__ <br /> ,I <br /> Inspection Form Included: <br /> _ <br /> Comments Included: - - - 5-993-/�'�4.- <br /> r <br /> �;juslness Rep' ignature Phone Number In ct gnature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect, i A M P L i ; 2 3 62081 <br /> ---- - - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />