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Waste Tire �jai .e & Inspection RepAonspection Report Number <br /> ■ ylj)j7 State of California y h ■ <br /> Calif IntCIWMB 181 <br /> egrated Waste entBoard Survey Form - Page 1 I1 - 1140751 <br /> Part A_Surve_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' O v + Routine Q Re-inspection Q Referral Q Observation <br /> Local r-- If Referral,choose referral type(Fill one) <br /> Identifier: {� JQ � .(o Lk Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0) - _VC w�� � ��G' � <br /> Physical Address 3 � - 0 �S� U <br /> 'H7 I 0 L v o mi!s �,�,. I -- - - --- - <br /> Inspection Date I a � l o / ` <br /> SAO A2+vn A 11!w <br /> Time In Time Out <br /> Business Rep Title �•, 0 AM � � Q 0 AM <br /> (f S PM �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 /> f �J Q Active Q Passenger Q Generator Q Outdoor <br /> - -- N <br /> O 0 Closed Q Altered 14 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 B Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 ENFORCEMENT STATUS <br /> - - - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 ® In Compliance - No Violations <br /> Q Q Other. § <br /> Comments 64' I�V�S G (�. �nS OCI _(► S`l�)Ir __�_S�- (1�S �u (;k <br /> No ,4 i0 w i c o S UIStut t0j)a f). <br /> inspection Form Included: QI'I rn <br /> Comments Included: 0! �Rep'sS <br /> BusiPhone Number Insp_ecrSignature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X F- X R 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C � <br />