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i <br /> _ Waste Tire Su & Inspection Report �pection Report Number <br /> '17>I• State of California _ i/�� y�''!{ `��` }�A{ <br /> "a' CIWMB181(NewU4,o4) y Form Page 1 - V L V V <br /> California Integrated Waste Management Board _ <br /> art A- S _ __BLUE O_ R_BL_A_CK INK PEN <br /> usinass Profile_ file _ — - - Insp ection Details - — <br /> -PID- inspection Type (Fill one) <br /> Fite Suffix: 1 d p� -3 - \ 14§ Routine Q Re-inspection Q Referral Q Observation <br /> -ocal If Referral,choose referral type(Fill one) <br /> dentifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ;usiness or Facility Name Inspected By Inspector <br /> 'hysical Address 3 611 <br /> o <br /> Inspection Date <br /> CAI D <br /> tom\ Time In ! Time Out <br /> 3usiness Rep Title D 0 AM O 2 0 AM <br /> ® PM 3 l 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> 0 Active 0 Passenger ® Generator • Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> 3 New Tire Dealer 0-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 /> 3 Service Station Q Hauler Q Agriculture Q Shredder 0 Other 1 vst� � ei(S � <br /> 'art B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> V A :HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> D Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> D Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> D Q PRC§42956-Registration/Decal in Vehicle <br /> D Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> J Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years � sr, � <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Refer " <br /> ^Q Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities a}�r <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ( r �. :; <br /> ® In Compttance„ o Vtoiations' Z <br /> J .. , <br /> 010 Other: § <br /> Comments �- l <br /> ,� 1 <br /> i <br /> T-61 tT_x o�c -yv` � _�s 5 1- e � -X%V _�s5\ s, <br /> 1 Il`��""`�'"` -�� -v`� Q-P►�S �c v1 p �"'' � -�c+r`� o'er-S3-`�c.- } <br /> Inspection Form Included: Q <br /> Comments Included: Q - -- - - - -- /" <br /> Business Rep's Signature Phone Number Ins c s ata Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK l Correct: Incorrect:( r ( M E X AIM F L E 2 Z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />