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a88 <br /> Waste Tire SuK & Inspection Report >pection Report Number <br /> 88 State of California <br /> CIWMB 181( e ) Survey Form - Page 1 11 - 1140882 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part_A-_Survey - _ - _ - - _ BLUE OR BLACK INK PEN <br /> rBusiness Profile Inspection Details <br /> TPID- Inspection <br /> d _ O f Inspection Type (Fill one) <br /> ffi - - - <br /> Site Suffix: — 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: — say) v"I C.� �;1� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name/ Inspected B <br /> P y Inspector <br /> Physical Address 3 / ��7�✓iGlJG �C <br /> I i Z -F Vo ILLP-j0 C4 - - <br /> Inspection Date �t f / 3 <br /> t F YIC�L 'wl r CA c� 'S Z 3/ <br /> Time In Time Out <br /> Business Rep Title OAM Q AM <br /> �± C) 2 O ® PM a sl 5 ® PM <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 0 Generator 0 Outdoor <br /> o 0 Closed 0 Altered <br /> ' GPS Latitude 0 Hauler 0 Indoor <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 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Irf A LHAULING AND MANIFEST REQUIREMENTS <br /> ...... Notice Of Violation <br /> __...__ ....... ......_.. 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 70 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 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 I CIWMB Enforcement <br /> Q 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 In Compliance - No Violations <br /> 0 Other: § <br /> Comments , <br /> Inspection Form Included: C <br /> Czve7>467-104 23 <br /> LComments Included: ®i <br /> t gnature Phone Number nspector's Signature Phone Number <br /> X �«W� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � I;� � � ,f►14 11213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co IV <br />