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Waste Tire S0&y & Inspection Repo Inspection Report Number <br /> State of <br /> CIWMBB181(New 04104) - ■ <br /> Survey Form Page 1 1 7 10 13 4 3 611 <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: y :`, -� I - O Routine O Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: LI r i%, ,, r ) j, 4 O CHP O CIWMB O Complaint 0 Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> k: <br /> Physical Address - ' 101 / 1 �. <br /> Street <br /> tr f Inspection Date <br /> Ifl/ <br /> Citv �� r State i ZIP Code Time In Time Out <br /> Business Rep Title 4 AM AM <br /> O PM r / J O PM <br /> f ^LF i I. 7 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I <br /> u (� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � 1 <br /> t Active O Passenger 0 Generator 0 Outdoor <br /> Latitude m ��o O Closed O Altered <br /> GPS O Hauler 0 Indoor <br /> p O Inactive 0 Truck <br /> Lo1.ngitude - O Planned 0 OTR 41 O End-Use O Container <br /> 0 New Tire Dealer 0 Auto Repair O Trucking Fleet O Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer 0 Auto Body O Car Dealer O Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A !HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 <br /> M / M / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> O 0 Other: § <br /> Comments7c 1 - <br /> rtt i,{} Cl-L, <br /> + j!LL- <br /> II&i�r�' l 1) iy / '�t t!(r �f' �'�d �J /,a.'✓G f' � 't✓(" <br /> 1. <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - <br /> Business Rep's Signature Phone Number I a or's S gn iture�F m Phone Number <br /> G, 62041 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X "v E ?f M P L EZ 13 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />