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Waste Tire Su, ay & Inspection Report Inspection Report Number ■ <br /> CIWMB;1'fornia <br /> (New04104) Surve Form - Patuye 1 I 1 - 1127726 <br /> California Integrated Waste Management Board Y J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 1 Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CJ�/I/1�� C��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name D Inspected By Inspector <br /> Ph i2a'fAdd Address <br /> ��� <br /> L <br /> I a$ �f�11ego C T- -- - <br /> Inspection Date OC. 0 <br /> ryevick kkm Cep. 95a,3 I l� <br /> Time In Time Out <br /> Business Rep Title : L _7 4P AM / ) (> AM <br /> 0 QPM ( (� 0 P <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 Q Passenger ® Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler ® Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - ® OTR Q End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder m Other t't)C.Y1 �n <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 /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 i 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 �}�,,,� � <br /> Au z) <br /> Inspection Form Included: QI <br /> Comments Included. Q ---- ---- -- -- <br /> usiness Rep's Signature Phone Number I s ct s gnature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrectt_'t )i � ; K <br /> ■ <br /> Co <br /> White Copy:CIWMB Yellow Copy:Operator Pink y:L ® ■ <br />