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Inspection Report Number <br /> Waste Tire SuOy & Inspection Reporr< ` <br /> ••-i11t. ClWMState f 81(New <br /> Survey Form - Page 1 I 1 - 1141044 <br /> CIWMB 181(New nage) Y <br /> California Integrated 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: / Y 8 s ! / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: pct .� O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - - - - <br /> Inspected By Inspector <br /> Physical Address <br /> Atrpof} YJC-A-� <br /> Inspection Date ® Cf o / O <br /> CA ct!s;2 O <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> oZ 3 ! PM A PM <br /> IJ1 [� f'lGtll� �AA,a WLCvw,- <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 /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler O Indoor <br /> o 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR O 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 Dismantler 0 Tire Derived Fuel <br /> O <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 0 Other m4 fro <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> __.._ 0 Notice Of Violation 0 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 m / m / m <br /> 0 0 114 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> I <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 /> riS <br /> ,Inspection Form Included: <br /> p O <br /> Comments Included: ® - -- - _��' c�l�L(S � C^d_t� y6 �O 6 Z <br /> Business p ignature Phone Number nspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X � \/ X A; � � 1��D <br /> White Copy.CIWM[3 Yellow Copy:Operator Pink py:LE <br />