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a . Waste Tire .E, iey & Inspection Repo. _ Inspection Report Number ■ <br /> State of California ` <br /> CIWMB 181( e ) survey Form - Page 1 I 1 - 1127456 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A-Survey _ _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` ?j ��j ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `� If Referral,choose referral type(Fill one) <br /> Identifier: � � CQA O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address // S C) <br /> Q'S 5' Pe r�m cA y e, J)r . <br /> Inspection Date I 0 0 t;'1 <br /> Time In 6 Time Out <br /> l/ <br /> Business Rep Title I L.J O ®AM ` ®AM <br /> { 0 P l O (� 0 P <br /> -— -- M v 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 /> 1 ° S Active O Passenger ®Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler 4&Indoor <br /> O Q Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Other ��1��y1 ccr1 �j� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A THAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O : Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 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 /> 0 0 <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 10 in Compliance - No Violations <br /> Q Other: § Lt <br /> Comments �Ut%.Cl�l�' �l".15�'�,,�• Y? �) �S <br /> 7I 1 e_ Fn 1i Q C.J';� n O i!' <br /> Inspection Form Included: Q <br /> Comments Included: Q t� o� vy� <br /> ! _ - usi ss Rep's Signature Phone Number In ct s gnature Phone Number <br /> INSTRUCTIONS ON BACKCorre- <br /> ct:0 incorrect: t ( , ,� P E 3 62081 <br /> _ I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:LE ® ■ <br />