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Waste Tire Suftlay & Inspection Report* Inspection Report Number <br /> -`� Stateof California - 1088209 CIWMB 181(New Survey Form - Page 1 11 10 8 8 2 0 9 <br /> California Integrated Waste Management Board <br /> Part <br /> Bus ess P of ley Inspection Details �_: BLUE OR BLACK INK PEN <br /> TPID- I I i ' _ OI Inspection Type (Fill one) <br /> Site Suffix: It Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local rf n U t <br /> -T l ri C�11 1 rl If Referral,choose referral type(Fill one) <br /> Identifier: J U . I , <br /> y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �tcaales 3 I _ i' <br /> Physical Address <br /> y-1 i v AN c, chick Ave . 11 J <br /> Street <br /> Inspection Date oFej � ) 3 <br /> I 5+o C_1vV on C.A q'S Z 0 G I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title , : Q AM Q AM <br /> Q PM Q PM <br /> t OWCa,rd zMrr, rman ci fi. _>u etYl�t. <br /> e <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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> I� O 0 Closed 0 Altered <br /> L� <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck t�,1t� <br /> Longitude — 1.1- 1 TI 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other �u I� ,I�wLe rll CeyT+c r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A i HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments \' <br /> Y-) q "JQ n o+e d <br /> F-a c'l 1 i-. clenArcx 0,�ro) 30 qecLC• Ra moa n <br /> 46"al rt C.OYriCCU�L Cierrms 011 teryice orl �orkL-3 rem oyc ate -Inr <br /> inn r� �tl `l OT ] S. Sr\io Ce S J12vv d Vlo�AtI oV,'Ck f t <br /> I1 Ins ection Form Included: <br /> J <br /> �r> , <br /> Comments Included. 0 <br /> Business Rep's Signature Phone Number I tor's Sign aturePhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X '( X I ft M P L E 1 t � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />