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AIIIIIII&IiI&111 <br /> r� °L Waste Tire S `& Inspection ''Repor ection Report Number <br /> ClWMState 181(ornia - Survey Form - Page 1 C 4 - 1 t� 7 .91. 3 61 - <br /> iii.�i CIWMB Ca f New 04104) <br /> } California Integrated Waste Management Board <br /> Part'A Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- [T] <br /> Inspection Type (Fill one) <br /> j Site Suffix: v ` j - Q Routine Q Re-inspection Q Referral Q Observation <br /> �E <br /> Local / ( If Referral,choose referral type(Fill one) <br /> Identifier: (. yl (,t ( e 1 "t2vul Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or.Facility Name <br /> Inspected By Inspector <br /> Physical Address y J E51 - I r n j f l-e-f <br /> Street <br /> l y , Inspection Date 0 J ! d <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0AM Q AM <br /> m • 1=0PM IT] . <br /> OPM <br /> I X21 bf ill I .' 'f(c f'-��t C c r 1 <br /> Operational.Status Tire Type Business Role Storage Type <br /> Ell <br /> Imo` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)Tire Count(Whole/PTE) LTJ�L_J Active Q Passenger Generator Outdoor <br /> Q Clsed Q Altered o <br /> GPS �atitude m • Q Hauler Q Indoor <br /> Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder [ Other <br /> -- --- -- -- ---- - — 1 vy -- <br /> Part B- Inspection of Waste.Tire Dealer, Generator, Hauler and End-Use Facility ENFO_R_C_EMENT STATUS <br /> V A ,HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation o Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle M O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> Q 0 Other: § <br /> Comments 1� <br /> zt �i t CCS- /F h f_ -I. t i ✓" i a'�Cg y1 tip ( :rte �' <br /> (.t -l �+clJ '" �/tE- <br /> CJ VJ✓l�t f � r,,t tM �, 1 C &io ---- <br /> 1 <br />,t .b77T.77___ <br /> Inspection Form Included: Q <br /> ... Comments Included: Q; L <br /> . siness Rep's Signature Phone Number Inspector's,Signature Phone Number <br /> ii INSTRUCTIONS ON BACK Correct: Incorrect: ( ) ' ; ,q Idry P 1 2 3 62081 <br /> - <br /> i ■ White Copy:CIWMB. Yellow Copy:=Operator Pink Copy:LEA ■ <br />