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Inspection Report Number <br /> =_U Waste Tire Su ly & Inspection Report <br /> It State California Survey Form - Page 1 I 1 - 1127499 <br /> CIWMBB 181(New 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: ` 0 a. 9 O I ii Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: 5a(, 10��(��� n Wink Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1{ Inspected B <br /> P y Inspector <br /> Physical Address 3 1 _ t o <br /> c5Q03Inspection Date 1 U <br /> 11,J Time In ` Time Out I v I <br /> Business Rep Title 1 r O AM O AM <br /> Vusl1 a C s�.S Ij h (1\ 3 J I* PM - PM <br /> q C. <br /> - - (1) 1 OperationalStatus i 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 /> 1 ® Active 0 Passenger I* Generator ® Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> O OPRC§ g P <br /> 42951 -Waste Tire Hauler Registration and Transport of Tires I <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 <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 Other: § _. <br /> Comments 1 I t <br /> -a_H l"It 5_�_ er _anu _1 I't U S v <br /> -DO V0ak_) Vf\1S ov arkA,% 04 CUj)CUr\, <br /> Noire= 1AA5 _ aui l., iL�- �jl1il'_ A51'�[/�_�V�+S1Q <br /> Inspection Form Included: Q <br /> Comments Included: Q00T 171724' - <br /> - Business Reps Signature Phone Number Inspe ors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr t: Incorrect: ,. (E=X P 2 3 <br /> White Copy: I Yellow Copy:Operator Pink Copy:LEA <br />