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L$„ Waste Tire Su :y & Inspection Report Inspection Report Number <br /> ,iaII State California 11 - 1140807 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey _ - -__ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- D / Inspection Type (Fill one) <br /> Site Suffix: © Routine ® Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Gil <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Otr4� <br /> z I I !J Ul�r lS C-fi W c <br /> �j <br /> C 1'7/ nn Inspection Date � .2- <br /> / <br /> `1 has Time In Time Out <br /> Business Rep Title / ® ® AM 0 AM <br /> 0P 0 0P <br /> r ' r Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) G (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> ....- 0 Notice Of Violation 0 Extension <br /> 0 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 /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <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 i 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> �T c c��f,•�.� cam. -�-y,� t ��Ltc, cy,�l �- <br /> .���-� — <br /> Inspection Form Included: 0 � <br /> x M- yv moi <br /> Comments Included: f _06 3 <br /> ® — <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> . / 01 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X , \/ F`x A'h4 P L 1112131 <br /> - -- <br /> White Copy:CIWMB Yellow Copy:Operator <br /> Pink COP&I, <br />