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Inspection Report Number <br /> Lieu_ Waste Tire Su. :y & Inspection Repor� <br /> State of California <br /> Wk <br /> Cgrated Waste <br /> Survey Form - Page 1 1 7 - 1006670 <br /> California Integrated Waste Management Board <br /> 'art A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 j –17 S D ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 aM Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other i <br /> Business or Facility Name •� <br /> Inspected By Inspector <br /> 5. <br /> v C/wCs - p � /k'k- <br /> Physical <br /> Address V <br /> Inspection Date / l / C> C <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> C, d (> ® PM -C' PM <br /> S� f ® <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (till one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 8 Active ® Passenger ® Generator ® Outdoor <br /> O O Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive O Truck <br /> Longitude – 0 Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder Other vA v�,-ct fL <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTS <br /> G o _m <br /> -- - - - <br /> 0ii <br /> Q ® PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 1 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trio Logs for 3 years _ <br /> O 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> O 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 /> O Q Other: §S1 <br /> Comments 5k- T v�C��? � <br /> l � <br /> �. <br /> " 1 l,'L 6\— e 1 ��l �,w• \t,�u, <br /> Inspection Form Included: 0 � �f f j�^�S C�Z A-�� 1 Comments Included: Q 1f 55 2S <br /> usin as 'P-r ignature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON B 'K r treG� �n II , ,1I p I j�l I 1112131 62os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />