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Waste Tire S► u y & Inspection Repor- Inspection Report Number <br /> rWaste <br /> of California <br /> CIWMB 181(New Manag ) <br /> Califorvey Form - Page 1 I 1 - 1141159 <br /> nia Integrated Wae Management Board 3 .............._ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) { <br /> Site Suffix: 1 1 1 1 Q ' l_ a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: �^ OQ r l � 04CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address [ 3191 1 / 1011 <br /> , <br /> Street i <br /> Inspection Date <br /> State Zlp r=t1t� Time In Time Out <br /> . 0 AM <br /> Business Rep Title OPM <br /> 1 O PMlJ.-A-M Lod] • Ep <br /> ................ ................... _......... <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> E � M Max:; <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> D <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> -- 0 Inactive 0 Truck <br /> i <br /> _ t0 <br /> Longitude — E 0 Planned 0 OTR 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 <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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <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§16459.3-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 i 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> O� Sit I 0 l 01 ELT 4t 400t__ <br /> r <br /> V l- <br /> 2.. ..:. y.> ,.;. ...,.•y_ .�_ .,.w v^., ......: ,.. ,. :....-. a ,... ,� { ...:i$!.,`."�'.. =`—:'1 <br /> Inspection Form Included: 0 d <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X l= X A. M. L E A 2 i 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />