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Waste Tire bw „ey & Inspection Repos t Inspection Report Number ■ <br /> CIWMB81California <br /> (New04104) Surve Form - Pa e 1 I 1 - 1143728 <br /> California Integrated Waste Management Board <br /> 'art A- Surveyy BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 t ' O O , - Q I Inspection Type (Fill one) <br /> Site Suffix: "1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` n C�un� If Referral,choose referral type(Fill one) <br /> Identifier: S 60 J p 16t'), 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> � (OACX 'TMf)5e0J�A')0n <br /> Physical Address Esc0&0 <br /> U125 <br /> r/A 453 Inspection Date / V y ' O <br /> Time In Time Out <br /> Business Rep Title Q O AM l� n 0 AM <br /> I PM p� ®PM <br /> C Ole- <br /> -- - - - - ---—__ - ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 1 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® 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 I HAULING AND MANIFEST REQUIREMENTS <br /> 0 00 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date T / m / M <br /> 0 0 114 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 EXE <br /> 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 <br /> 0 0 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> § Y q - <br /> § Y q <br /> 0 0 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § 1 <br /> Comments <br /> was <br /> Inspection Form Included: 0! V/_WA/_1W' 4_cPA9 <br /> �-L13YA <br /> Comments Included: ®, - ) <br /> usiness Rep's Signature Phone Number Inspec is Signature 7hone Number <br /> - / � 62081 <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect X AP ,V-�� I E Xj A M1 P E1 ( P 12131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />