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Waste Tire Asy & Inspection Repd ftinspection Report Number <br /> State of California ■ <br /> CIWMB 181( eaSurvey Form - Page I I 1 1127719 <br /> California Integrated WasttMan <br /> Waste Management Board <br /> Part A- Survey___ BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �� Inspection Type (Fill one) <br /> Site Suffix: XV 41 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r-- If Referral,choose referral type(Fill one) <br /> Identifier: S /� V Q�/��;^ Cy0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l "I 1 t Inspected By Inspector <br /> b�e-�N GcLsdu Ui-4 scuuve- <br /> Physical Address 3 <br /> Inspection Date 1 i 0 <br /> U <br /> Time In Time Out <br /> Business Rep Title <br /> l m l 0 AM 0 AM <br /> /�SS� � � 1 (. • PM � 5 � PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> 'tire Count(Whole/PTE) <br /> n� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Xf�f� <br /> ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered NIA <br /> GP.� Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 10 Truck <br /> Longitude — 0 Planned 0 OTR 0 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 ® Other J '`��� <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 I Ffl <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments Q ]1�1(`S^n,�,0(1 W jL o,,T jk nuc <br /> -ta\3\k IDA fk-,R eA- 4 C-(3y)( <br /> ac, <br /> Inspection Form Included: 0 l / 1 Q <br /> Comments Included: 0 oj34o?-/ alA <br /> ��� �si ss p' _ Ph a Number Inspec_ is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ! + E X I A WPIL I 5er I 13 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y' <br />