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Waste Tire Sump* Inspection Report,l <br /> -- ction Report Number <br /> EEEE State California SurVe Form - Pa e 1 I - 1127547 <br /> CIWMB 181(New ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLU_ E OR BLACK INK PEN <br /> -- - - - <br /> Business Profile Inspection Details <br /> ' TPID- r � � _ Inspection Type (Fill one) <br /> � � <br /> Site Suffix: ' -I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: SckyA -azai I 0 CHP Q CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> (eA k7r- 7-7 � � l- � Ai�-c�n� ,� 1a)Physical Address /^ ' �( <br /> _ Inspection Date / /'� � ) '7 <br /> Time In 6 lJ Timle Out <br /> Business Rep Title Q AMIQ AM <br /> l.J D QPM <br /> Q� � v QPM <br /> -� - -- Operational Status Tire Type I 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 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler I 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR Q End-Use ® 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 0 Other <br /> _ --I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> "`HAULING AND,MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cpmpliance Deadline,, <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W /.m m <br /> 0 ' 0 '14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 j 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (RequfredforNOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers }',Referred I 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 <br /> In Compliance No Violations II <br /> 0 0 Other: § <br /> Comments C' __M` Pech-z� . _Ptk j{IneL cinA1-_._�TJk,._ <br /> cam IVl ' <br /> J �7� <br /> - <br /> Inspection Form Included: 0 <br /> i <br /> Business Rep's Signature ne Number yG Insp r kIE <br /> Comments Included: ® - - - - - � IR� <1pho 65 Number <br /> - <br /> P 3 62081 <br /> INSTRUCTIONS ON BACK Cb a <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />