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Waste Tire !"e & Inspection Reppe Inspection Report Number <br /> ■ � Illi State of California Y ■ <br /> I1 - 1143716 <br /> CIWMB 181(New 04104) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> ,t A-Survey_- - BLUE OR BLACK INK PEN <br /> -- - -- - - <br /> iness Profile 1 Inspection Details <br /> I PID- Inspection Type (Fill one) <br /> Site Suffix: 5 L O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , ' n Coin Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name kl <br /> Inspected By Inspector <br /> t <br /> Physical Address 39 A-vrLm tc)ul ic., <br /> /b 250 L.xn-e, R L• CA - <br /> Inspection Date / { JJ� / 0 <br /> Time In Time Out <br /> Business Rep Title � � � � O - <br /> AM � � � � 40 AM <br /> PM �PM <br /> �X. �r l C.VV� T 111 �C�Y1Ct ✓ — - - <br /> --- -- -- Operationaa l Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 7 ' Q Active Q Passenger ® Generator Q Outdoor <br /> 0 ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive O Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other 67YIG►e..,,Iif <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§ - i Q Notice Of Violation Q Extension <br /> 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 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 EX7J <br /> 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 <br /> en/S—A <br /> ,,,Ispection Form Included: Q �D � qd7S <br /> Comments Included: ® - 0- S 70 - -v0?- 6�� <br /> Business Rep's Signature Phone Number I ctd s ignature Phone Number. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I l ;-�- l 62081 <br /> -- vlJV1PI-� t1J11 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />