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E <br /> WInspection Report Number <br /> �ste Tire S*ey & Inspection Repol* ■ <br /> H6&us Staf hof California <br /> Cel CIWMB181 <br /> Waste <br /> S u rV ey .Form - Page, 1 3 -1- 0 3 7 <br /> California Integrated Waste Management Board � <br /> Part A- Survey :}-` BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Insp1jqj ection Type (Fill oneO - <br /> Sie Suffix: L/f I r ` ORoutine Re-inspection Referral <br /> O Observation <br /> Local C", If Referral,choose referral type(Fill one).--' <br /> Identifier: 41/t,41/t, �( Oouf,�bl' <br /> Q CHP Q CIWMB .Q Complaint. O Educational Visit Q Other <br /> Business or Facility Name Y Inspected By Inspector <br /> 2 <br /> Physical Address <br /> Street / /.. <br /> rj 11 (� � Inspection Date <br /> l Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title O AM O AM <br /> 't Y1 � EE : <br /> m0PM m 0PM <br /> J c_ ► Va.Ke M ct .Gc c�r- - - --- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> C) Active 0 Passenger (3 Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> O O Inactive Truck <br /> Longitude. – Q Planned Q OTR (0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder .0 Other I f)11-f, ( pill i l(,a Val-01" <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A ;HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires. <br /> O O PRC§42.953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / FTI <br /> r <br /> O 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Numberfrom'CIWMB j <br /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> ... ------— -- – - --._.......... <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years J <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement I <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: § y [ ! <br /> Commentsnoted � C �3Y1 {&Jmi t <br /> p <br /> f0 tQ�� `�C)tioy—I4 .51(yaC"� �fC�vt�t�rC( OM 010 �AC �PorZ per(v✓rl'1e �G��'� �ta <br /> r r <br /> Li of J �c�c2�G�F'" '�J�tS� QrtC Ga. tlP�1t<'�P S X11 - gut.}tit��(d� raJE ty0-C-� Yom` <br /> b2ye b.UVl r eNi6V(; O11F _(���C 1_ 'n S _l�i'1 C C C/IGf Q6'l ��_S4 <br /> Inspection Form Included: <br /> Comments Included: 0 � � - / , / , • , ,�< " <br /> Business Rep's Signature Phone Number Ins ctor's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ; `/j M P !� 1 1 Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■' <br />