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Inspection Report Number <br /> Waste Tire Su 4.1y & Inspection Report <br /> eft State California Survey <br /> Form Page 1 1 y 1141283 <br /> CIWMBB 181(New 0 g <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 6 5 V - O l ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L)I C_LJL4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> C t C Auto - <br /> Physical Address G 0 <br /> gM,� -AoY4 - <br /> ��, Inspection Date Q � � __7 <br /> Time In UU Time Out l� [ <br /> Business Re�p1 ` \_ Title / / / O AM : O L/ 0 AM <br /> � /V � F� �JO►1'�� ��� � `PM � 40 PM <br /> — - y 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 /> v ®Active 0 Passenger ®Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude t�Hauler Olndoor - <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ®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 ® Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> IV j A HAULING AND MANIFEST REQUIREMENTS <br /> ............ <br /> O Notice Of Violation <br /> Extension <br /> 0 O i <br /> 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 <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 <br /> (Required for NOV or EXT) <br /> __.._ <br /> O O <br /> 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 f 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 B In Compliance - No Violations <br /> .0 . 0 Other: § <br /> Comments <br /> Inspection Form Included: 6 pl� DG� _ q. <br /> Comments Included: ^G�� <br /> Business Rep's ign_a a Phone Number Inspe 's§(griature Phone Number <br /> -- <br /> INSTRUCTIONS ON BACK Correc ncorrect: III <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />