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Waste Tire Sur Y P p& Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Pagel - 1141196 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L Inspection Type (Fill one) <br /> Site Suffix ' + 1 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ; C If Referral,choose referral type(Fill one) <br /> Identifier: - - <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 - (�_ <br /> I ,--µiii <br /> r- <br /> -....�...._._...._....... .... ..... .... _.__�_..._... .... ..... _.__._......_._._._.. ._..._..._...m._ <br /> Inspection Date 3 o �� `� �� 1 <br /> t 6. 1 � � �.._�__. .. <br /> O StL p�; 7;R U„,„gyp Time In Time Out <br /> Business Rep Title O AM <br /> O AM <br /> O PM �� O PM <br /> ........... tF/u\CL' (Pfl�t N{(j _ <br /> - Operational Status Tire Type Business Role Storage Type <br /> The �Qllnf�WholeCP'TE� p <br /> (Fill one only) (-ill all that apply) (Fill all that apply) (Fill all that <br /> apply) <br /> .. . ,..gid. <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 1 O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0Inactive 0Iluck <br /> Longitude <br /> 0 Planned 0End-Use 0 Container <br /> 0 OTR <br /> Business'rype (Fili all khat 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 m / IE / 11-1 <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 (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/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 0 in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments i <br /> �_+_. i..I l� j}� r7J'� IC.i• l �,_; :;1-1- -�i�i ` t LLL t 1'i, 4- <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> a 62081 <br /> INSTRUCTIONS ON BACK Correct incorrect: v I i - 3{ <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />