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Waste Tire SSeyInspection Report Number <br /> & Inspection Repoi <br /> CIWMB81California <br /> (New04104) SForm - Pa e 1 Ii* 1088325 <br /> Callfomurvey ialntegratedWasteManagementBoard + � <br /> t A-Survey BLUE OR BLACK INK PEN <br /> _ <br /> iness Profile Inspection Details <br /> i r'ID- Inspection Type (Fill one) <br /> Site Suffix: 3 Cq Ll Q O Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: )CAA "S0Gtv1 /+n C CAA IZ// Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 9 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 9 Ip AM / _7 AM <br /> O PM ` ( l 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 Q Passenger Q Generator Q Outdoor <br /> GPS <br /> Latitude o 40 Closed Q Alter/h Q HauA//� Q IndooAIIA <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair 4&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 Q Other <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 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 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 DCT) <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 /> I <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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �m�714� SnS/kGh�►�► rc`�IC�C7�if-c `lVl•�?� r�«:fL Aly �fblc„�j�IY! 1 CN & Ga <br /> ac���v �S , I��ecoY,-,rrr�rr�� clave 7r _ LSON5791-0/. <br /> ...apection Form �nc <br /> ncluded: Q <br /> Comments luded: Q '— �—�l �~� �� <br /> Business Rep's Signature _Phone Number Isp cto gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 101LIE1 1112131101L <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />