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nspection Report Number <br /> Waste Tire SAW & Inspection Report <br /> State of California �# P� r'S <br /> California Integrated Waste MB 181 eManagement Board Surw 04104) vey Form - Page 1 - ! j 7 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t7 Q Routine O Re-inspection Q Referral Q Observation } <br /> Local - I If Referral,choose referral type(Fill one) <br /> Identifier: !; O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> c , i <br /> Business or Facility Name C' Inspected By Inspector <br /> Physical Address <br /> 4� <br /> Inspection Date o 1 <br /> Time In Time Out <br /> Business Rep Title O AM I O AM <br /> O PM I O PM <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 /> ' Q Active O Passenger O Generator O Outdoor <br /> Latitude " Q Closed O Altered <br /> GPS Q Hauler 0 Indoor <br /> Q Inactive O Truck <br /> V <br /> Longitude — O 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 O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A i•ALILiilyu_A1i�jij f;614n=EE►i kEQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments Cit i. I 1 t- /Yi - p w I�L;, �d';-(� k E' m l rL1 �'! �.L A)r <br /> L1 y I VV rJ r' {Ke �5ev- ✓) ' <br /> !? T ry :�trILf Kr'bl VI0W--C1 MO <br /> Inspection Form Included: O <br /> Comments Included: 0 <br /> ,Business Rep's Signature Phone Number . Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X jl�, \ ,E XI A MI P I L I EI I 1 12 131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />