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Inspection Report Number <br /> Waste Tire Survey & Inspection ReportState <br /> ClWM 181Cali(New Survey Form - Page 1 1 5 - 1 0 7 9 3 2 7 <br /> CIWMa 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G _ Inspection Type (Fill one) <br /> Site Suffix: ,,Z 6 7 / 5 9 G 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A14 rw 4-v A <br /> Physical Address 3 / f' TU/3/.3-0T/Y/F-V A <br /> .2 3.2-3 ZCV 4- .e: <br /> Inspection Date 0 5- -3 <br /> Time In Time Out <br /> Business Rep TitleAM <br /> * AM 7 O PM <br /> Q PM <br /> J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 40 Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — End-Use Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other //4yrf .r `O�t <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> 10 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires j <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 /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 <br /> Q O Other: § <br /> I Comments <br /> � �y �o�� � ✓,b a�p�, U � <br /> ---------- -- <br /> Inspection Form Included: O �9 <br /> Comments Included: Q vz0� 57lo <br /> si <br /> Buness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ct: ncorrect:X V 1E X A,M P i E! 112 3 <br /> White Copy. IWM Yellow Copy.Operator Pink Copy LEA <br />