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r QQ <br /> ■ s & Inspection Report <br /> pection Report Number <br /> „Frated <br /> aste Tire S u�° �, �, p p <br /> of California 11 - 1140871 <br /> B181(New"041 Survey Form - Page 1 <br /> CalifWaste Bang merit Board <br /> BLUE OR BLACK INK PEN <br /> Part A- SInspection Details <br /> Business Pro_ --- - <br /> TPID Inspection Type (Fill one) <br /> Site Suffix. ' ✓ T 0 r Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identme: �LtM Ce-q'x,L"Y__� Le"rwt'✓r"`1 O CHP O CIWMB d#Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V ` J Inspected By Inspector <br /> 5,Aeed <br /> Physical Address � ✓ ( _ <br /> t 0 A'Ylal-zCl4 <br /> 5) 5- ��1�t K d -- <br /> C Inspection Date 0 I � U (J <br /> _`P_o c:g_Fv�v ���5 Time In Time Out <br /> Business Rep Title ® AM AM <br /> y� MIAI I 0 O PM t 2 I © ® PM <br /> f /���// '�u — 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 /> ®Active ® Passenger ®Generator I& Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader <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 __.__; __ O Notice Of Violation O Extension <br /> tion and <br /> ansport <br /> OO PRC§42951 -Waste Tire auler ith RegsteredegistraWaste Tire rHaulersof of Compliance Deadline <br /> O O PRC§42953-Contracts a is w <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§ 18459 -Res Entities Complyingwith Manifesting Requirements Date <br /> O O Responsible [1:1 <br /> / <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years d!CIWMB Enforcement <br /> Q O 14 CCR O Referred§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities 3 <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations y <br /> O O Other: § - <br /> Comments <br /> (Inspection Form Included: Q <br /> Phone Number <br /> ® <br /> Comments Included: Business Rep's Signature Phone Number nspeetor's Signature <br /> p --g 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X <br /> 3 <br /> PY� tor Pink Cop LE <br /> Yellow Co operator Whitr�copy.CIWA413 p _ <br /> rink Copy'LEA <br /> ��� <br />