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== Waste Tire ce&y & Inspection Repan Inspection Report Number <br /> State II88 <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1141264 <br /> CIWMB 181(New nage) Y ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey - BLUE OR BLACK INK PE_N_ <br /> Business Profile i Inspection Details <br /> TPID- Inspection ction Type (Fill one) <br /> Site Suffix: 51-1 3 0 l <br /> l ® Routine Q Re-inspection Q Referral Q Observation <br /> Localnn//11 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 /> Atl Irl k'A �tx Vl I"l i l rc)e s G - ( v <br /> Physical Address ( d / �� ✓�� <br /> � <br /> L� ^ Time <br /> Date / O <br /> S�� l� I CCS �Saa6 T. l <br /> me In Vim 0 Time Out <br /> �u-siness Rep Tiittlle� I 7 <br /> O AM / O AM <br /> Ci a PM — -.-Q 7 -® PM <br /> —-v - --- -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O Q Active ® Passenger ® Generator Q Outdoor <br /> O 0 Closed ®Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS <br /> - --- -- -- ------ -- Q Notice Of Violation Q Extension <br /> Q Q 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 m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® - — �� -- <br /> Busines ignature Phone Number Insp or' g ature Phone Number <br /> __............_ 62081 <br /> INSTRUCTIONS ON BACK C rect: Incorrect XV f <br /> X > P L 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />