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Waste Tire Su, ..y & Inspection Report inspection Report Number ■ <br /> State of California <br /> CIWMB 161( e ) Survey Form - Page 1 I 1 - 1140620 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix:— Z S Z f 0 r/ Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one). <br /> Identifier: � � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> l.�u <br /> Physics Address 3 4f - / /1� �0�-✓�� <br /> 23'7-0 <br /> - Inspection Date <br /> Time In Time Out <br /> Business Rep Title © � 1z � 0 AM 0 AM <br /> ® PM O a►�] S 6 0 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 /> _�& Latitude - 0 Hauler -O-Indoor - <br /> 0 0 Inactive ®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 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 / m / m <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 1 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 In Compliance - No Violations <br /> Other: § <br /> Comments <br /> ��.r l,'��--�. Com,uwFl�yc.�� t s c�Lra�caQ. l�.lcz,✓v � �� �x _�-cam <br /> D�l ,.>a -- <br /> Inspection Form Included: 0 <br /> Comments Included: 0spect <br /> Business Rep's Signature Phone Number Inor's S nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X I :X A M [4112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />