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Waste Tire Slat. sy Inspection Repor, Iri-„ection Report Number ■ <br />iEBil CaliforniaState of <br />CIWMB 181 (New <br />Il - 1143764 <br />California Integrated Waste Management Board S u rvey Form - Page 1 <br />Part A - Survey- BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - I C 1 _ ( Inspection Type (Fill one) <br />Site Suffix: J Q Routine 10 Re -inspection Q Referral Q Observation <br />Local C �1 ) If Referral, choose referral type (Fill one) <br />Identifier: Jan V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />Physical Address Ren E5C, oCoil l f. Clnv.� � c,r l�u> J --— <br />5 Inspection Date � � v ( � l <br />(S�a�r� ' ” 0 (A Time In Time Out <br />Business Rep Title 0 AM 0 AM <br />O PM V PM <br />--- - -- - -- -- —- - -- -- - - Operational Status Tire Type Business Role Storage Type <br />5 T r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />Tire Count (Whole/PTE) J <br />Active ®Passenger � Generator 11P Outdoor <br />O Q Closed Q Altered <br />GPS Latitude Q Hauler Q Indoor <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 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 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 />PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date 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 1 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 es2v.bV►S �c--1(�Sj�J� a�1[-"6n._�I_1_�L.-ct��C-�(�3@e,Gi�r-�__Ppf(11 <br />-L <br />04. d kC— C%f \ok -1 ru., --TO Ik OVJr\A1 —\AA - <br />Inspection Form Included: QI -7 <br />Comments Included: Q - ���- � / �� <br />1111 in ss ep's ignatu a Phone Numbers Insp�'sSign.t.r"e one Number i <br />INSTRUCTIONS ON BACK Correct - Incorrect - %,+ �/i -1 a a 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Co : L ® ■ <br />