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Waste Tire 810y & Inspection RepdO Inspection Report Number <br /> State of WMBali(New 04104) S <br /> CIWMB i61(New urvey Form - Page 1 1 3 - 1 9 7 9 3 8 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / ,I / - D Inspection Type (Fill one) <br /> Site Suffix: �/ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / , If Referral,choose referral type(Fill one) <br /> Identifier: — O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name lL Inspected By Inspector <br /> V,-f7-4 l�A <br /> Physical Address 3 9 - d / ���j�� ✓� <br /> h, ,9 /L: GGA Z � 8 - -- �y <br /> Inspection Date / rJ o (� 7 <br /> .5� ►C1614c 9� rQ <br /> Time In Time Out <br /> Business Rep Title 0 AM /1 o O AM <br /> twl/j,- C�iL tJ / ® PM I ® PM <br /> - V Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1-7- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> * Active ® Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - End Use Q Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer ® Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENGORGEMENT STATUS <br /> -- - - <br /> V A HAULING AND MANIFEST REQUIREMENTS _ <br /> - 0 Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / [_ I 1 <br /> L_ I I ! 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 /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 Q Referred!CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations <br /> 71 <br /> Other: § <br /> Comments ,u37�i7�p !� t r �3� +J• CTot `� ��D�/i Gei L � <br /> 9 <br /> Inspection Form Included: O <br /> Comments Included: 0 <br /> Business Rep's S' nature Phone Numb"er1 Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr c : Incorrect. _"f �/i E'' A p � � 1112 3 62081 <br /> White Copy:C Yellow Copy:Operator Pink Copy:LEA <br />