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Waste Tire SU y 81; Inspection Reportinspection Report Number <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140999 <br /> California Integrated Waste Management Board <br /> Part A- Survey__ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ) 3 U 9 (o - <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SC�J✓� �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By --- - -- Inspector - -- <br /> I <br /> Physical Address 3 1 - 0 ��v✓�v t ►�c�e�a tY�^ <br /> o so o S • f k��rl�•v` . <br /> Inspection Date C) / Z Z? (, <br /> CA Cl S Z.5-/ <br /> Time In Time Out <br /> Business Rep Title l 3 ® AM / 3Q ® AM <br /> Q PM O PM <br /> Operational Status, The Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator ® Outdoor <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use ® Container I <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 CC, C-+4 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 /> Q ' PRC§42951 -Waste Tire Hauler Registration and Transport of Tires li 0 Notice Of Violation 0 Extension <br /> Q Q 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 /> Jll <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 1 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 81 <br /> 8 <br /> 0 1 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 /> 011 0 Other: § <br /> Comments <br /> -�wlj, c—dl -t-f v(t) <br /> Inspection Form Included: 0 y �~ <br /> Comments Included: '\`�w�'�- --awn" `�"3ss3�'/ �Gq) q&.? 01oZ3 <br /> Business Rep's Signature Phone Number nspector's Signatur Phone Number <br /> > __- 62081 <br /> INSTRUCTIONS ON BACK Core :0 Incorrect: X � .€` x l�l k, 1112131 <br /> White Copy: IW Yellow Copy:Operator Pink py:LE <br />