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Inspection Report Number <br /> Waste Tire S, .:y & Inspection Repor <br /> State I3 California I 1 - 1141293 <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPfD- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection • Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sao, '�owqolYL 6X'q 0 CHP 0 CIWMB Complaint 0 Educational Visit 0 Other <br /> Business orF,acillity Name Q, C Inspected By Inspector <br /> Physica�lAddress941-5 40,ze- <br /> — <br /> �r <br /> D� Inspection Date U a e) 0 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> A PM O PM <br /> � t1os c. v o S owne I - - <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 /> O ® Active ® Passenger • Generator • Outdoor <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Hauler Indoor <br /> 0 0 Inactive 0 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 0 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 D� <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other 'E/ecy-0 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> _.-_ Notice Of Violation 0 Extension <br /> - --- - - - - ---- - <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> T T T <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I I�I / p <br /> 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB L I t I I I t I l <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> t7 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> C"t <br /> Inspection Form Included: 0 <br /> Comments Included: ®, --- - - ---- - -- <br /> Business Rep's S" Phone Number Insp c i ature Phone_Number <br /> - — -- - `#' t��� � � - _ -- 62081 <br /> INSTRUCTIONS ON BACK ncc� l : a` E X A P L Ej I Z 2 3 <br /> White Copy:CIWMBMB Yellow Copy:Operator Pink Copy:LEA <br />