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`Inspection,Rep�rt�Number <br /> k0CIWMB <br /> .Waste 1Tire Suy &:.inspection Reportr�r � <br /> State f81( ewSurvey -Form - Page 1 �1 2 - 1 3 6 <br /> 181 California New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- k` ) Inspection Type (Fill one) <br /> Site Suffix: j ti t J �J i_ Q Routine Re-inspection, Q Referral Q Observation <br /> DLocal If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physilbaal Address J1 Ak <br /> Street Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM AM <br /> m • m0PM m 0 P <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 /> Active 0 Passenger (jD Generator Q:Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> O Q Inactive �Truck <br /> Longitude — Q Planned Q OTR (b End-Use 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 r /kf <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (a Other Fr t 1t'31 $ 5}U'/((('f <br /> , <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> Q Q 14 CCR§18459.1 (a)'(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1. -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Q 14 CCR§18461-.Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments-TKJ,� fa C6.o Li- U.kl 5 a -oSi2(de(( �` C f. !n l'DY i�hC 1 l on ��JI y Gt tl i;✓) I I-r <br /> 1 <br /> 011 ?)`l3(} WI Go d 1(�a`l. , 61 -vic A Il �f rr�t le a W eire o�'+l�c �� r✓► I � �-cl� <br /> ��' 1-{,, ►�EC`�C E�tl`J(-� ��'(�l It i 1�'l� (r)) t lr� eft r j tz:s1t�;;l, � cctc,Vr:� t1JG�r� �}c.r{ �� S��Q <br /> Inspection Form Included. Q <br /> Comments Included. 0i ., <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 1. A� P L`E 3 62081 <br /> u 1' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />