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== Waste Tire Su 4 & Inspection Report 'nspection Report Number <br /> sea <br /> AO State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1140885 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 ' Inspection Type (Fill one) <br /> Site Suffix: Z G1 - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f17 /; , , YJ / _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Gc �FIK <br /> Business or Facility NamiI <br /> Inspected B <br /> _ P y Inspector <br /> ,/tet)it`1 Pi C-k" <br /> ze-a Circ` ., G <br /> Physical Address <br /> �'� tyJCCir <br /> Inspection Date <br /> CA <br /> Time In Time Out <br /> Business Rep Title ® AM _ Q AM <br /> PM ® PM <br /> J <br /> 1 I � • ` 0 Cat s�)v �,?_fes - - <br /> Operational <br /> p s l Status I aghBusiness <br /> � ineole Storage <br /> Tae <br /> (Fill only) (FII at apply) ( I allthat apply) ( la pp I <br /> y)Tire Count (Whole/PTE) <br /> ® Active 1 Q Passenger Generator ® Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 I Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 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 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 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 I Q Referred f 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 i <br /> in Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> c -,qo fees! <br /> Inspection Form Included: Q (` <br /> X .2UC' C2o9> y(vyr o4 zj <br /> Comments Included- <br /> OF <br /> ncluded: ® - ---- - ------- - - - -- - - - - -- -- - - <br /> - - <br /> Busines ep's Signature Phone Number Inspector's Signature Phone Number <br /> r 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �,. 7f I A Mtf I L 1I`2131 <br /> White Copy CIWMB Yellow Copy.Operator Pink opy: <br />