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Fg, Inspection Report Number <br /> Waste Tire Su :y & Inspection Report' <br /> 110 State of California — <br /> CIWMB 181(New Survey Form - Page 1 I 1 1140668 <br /> California Integrated Waste Management Board <br /> Part_A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' Z - Inspection Type (Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> c <br /> Identifier: cvn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address - ! v <br /> l o lit Z S . 14,lclv , Q,,K. <br /> /� Inspection Date d Q I l <br /> cA 1S'ZSl I l <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 1 0 A PM <br /> ® PM <br /> rz"y �rt,�d Sh .rvl ce vct5er - <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) f 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �( S. <br /> ® Active Q Passenger ® Generator A Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet 06overnment Retreader Q Dismantler Q Tire Derived Fuel <br /> I 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 1 ENFORCEMENT STATUS <br /> V <br /> A j HAULING AND MANIFEST REQUIREMENTS Q Notice of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliancy deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle `? <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements 1 } / <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMBy <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years t <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 <br /> Q Q Other: § <br /> Comments <br /> r <br /> )nspection Form Included: Q' l <br /> I <br /> - Comments Included: - - - -4 �fi - - - �.ZC JJ'fb$ 06 7-3j <br /> - I Busln Rep Signature hone Number spector's Signature Phone Number <br /> - - - <br /> - — - --- - <br /> 62081 <br /> INSTRUCTIONS ON BACK R, ^ ��.d .Ak ( A14 1 2131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />