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$"' Waste Tire Su( & Inspection Report nspection Report Number <br /> :.� Y p p , <br /> State of California I 1 - 1140736 <br /> w 04104) <br /> California Int gr ed,Wast eManagement Board Survey Form - Page 1 <br /> Part A- Survey __ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection 5 _ Inspection Type (Fill one) <br /> Site Suffix: <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 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 /> Physical Address J <br /> ti 1J O'�.V'I"1CJ✓� <br /> ,24-S & A,IrP�r } W� - - - <br /> Inspection Date C) / U -3 / l a <br /> 9S 33 C, 1 <br /> Time In Time Out <br /> Business Rep Title Q AM ff Q AM <br /> n � PM � 1 02 � ® PM <br /> TD�C<<V` I" I S� © 9"C - ►"VA.V1.4 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 /> ® Active ® Passenger ® Generator B Outdoor <br /> O Q Closed Q Altered <br /> - _.- Latitude -- — - ---- -- - &-Hamer 0 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 /> 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 /> 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 /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Q --- -- ------------_._...__ __-.-...._..._._....... ....__..__ -_—. Q Notice Of Violation Q Extension <br /> 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 / FT] <br /> / 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 1 Other: § <br /> Comments m '11, / <br /> UliA t1�1��`ca'(4r_A - [s�^ ::6-< C�C t� a_• ��- .1 ar__ (L uw t iA C <br /> Inspection Form Included: 0' <br /> Comments Included: -- 3 <br /> Business_ R 's Signature p g Phone Number n pecto s nature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect:� Incorrect; X� �, P <br /> White Copy:CIWMB Yellow Copy:Operator Pink t <br /> :L <br />