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Waste Tire �*y & Inspection Repofolnspection Report Number <br /> '.iA State of California ■ <br /> Calif lnCiWMed'Was(New <br /> 04104mentBoard Survey Form - Page 1 I _ 1127917 <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` t Inspection Type (Fill one) <br /> Site Suffix: , 3 8 1c7 1 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local /�' If Referral,choose referral type(Fill one) <br /> Identifier: ��r,J y�. C.�CLt4� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !/ Inspected By Inspector <br /> Physical Address 39 - Q �- - M <br /> 'Obll _ /� / I innY� C7tJ <br /> ( Inspection Date I / ` 1 / i 1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Z <br /> PM --2- ,2 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 15 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> . # Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 /> 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q j 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 EXE <br /> I� <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> CIO <br /> Inspection Form Included: Q ^ <br /> Comments Included: IS -- <br /> usiness Rep' ature Phone Number_ In a o g ature Phone Number <br /> - -- - I— — - --- <br /> ��,,����.�. 62081 <br /> INSTRUCTIONS O BACK orrect: Incorrect I Y �X A �. 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop : ® ■ <br />