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r ,' <br /> ■ �Lpp W�Se�Tire:S ��& Inspection Repo ��Inspection Rep®rt Number ■ <br /> 6Bi State of California _ _ 7'1 <br /> � <br /> CIWMB181,(N"04104) Urvey Form - Page 1 - 1 3 0 7 0 <br /> California Integrated Waste Management Board <br /> Part'A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID / �} Inspection Type (Fill one) <br /> f Site Suffix: .Q Routine Q Re-irispection Referral Q Observation <br /> I Local( If Referral,choose referral't�pe(Fill'one) <br /> Identil<ier: Jat:( (�r✓( �)n �iU`tii.(/L Q CHP Q CIWMB (3M1Complaint Q Educational Visit Q Other <br /> I Business or Facility Name' Inspected By Inspector <br /> Physical Address �✓ JQi/�l,� t_ Pt,f, '? 1 <br /> Street ' <br /> (� Inspection Date <br /> I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title V0 r P -7j Fq] <br /> G OAM 0 AM I J (D PM ! ( Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I <br /> ('`� 01 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �f <br /> ' f Q Active @ Passenger 0 Generator Outdoor <br /> O <br /> Latitude Q Closed 0 Altered <br /> GR;S m • Q Hauler 0 Indoor <br /> ' Q Inactive oma':Truck <br /> O <br /> Longitude - 0 Planned Q.OTR (2) End-Use E) Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br /> Q..Service Station Q Hauler O Agriculture Q Shredder ,i (3 Other roll(,(t "., (U&al,( �10 <br /> a' <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation O-Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> (0 O 14 CCR§18459 -Responsible,Entities Complying with Manifesting Requirements DateMI ; mm <br /> 0/' <br /> Q O 14 CCR§18459.1 (a)(,b)(c)�irtFProgram ID Number from CIWMB V , <br /> O O 14 CCR§18459.2.1.-/Submittal of Manifest,Forms and Tire Trip Logs within 90 days (Retluired for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i@ 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> (D. O Other: § <br /> Comments <br /> nS t Jf7n -� i �t�j ConGur ec yj. 0 <br /> 1 <br /> lI L�r 10L6 ftfQSa4 Iry wt1(n0u11perr��� <br /> oo f7c,s,t c-#e.cf <br /> Po nfoSKE Ca� 6 [C,vtS L h <br /> ` <br /> lq.d 7 ! 1ycL �Pl_F))e_1Trcf� � 1 / - J <br /> — _,.p•.. <br /> is <br /> Inspection Form Included Q)! J <br /> Comments Included: 31: `- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> r�1 .� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ')� X .A N!I P I L I E I 111.2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> _e <br />