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rAbk AWL A90L <br /> Waste Tire Sdk . ey & Inspection Repo, , _ Inspection Report Number <br /> State CIWMB California 181(New <br /> I - 1140755 <br /> California Integrated Waste eManagement Board survey Form - Page 1 <br /> Il Part A-_Survey _ — BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � � � � � � _ 0 � Inspection Type (Fill one) <br /> Site Suffix: ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: S CL<) J QC�1,x,111 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 1 <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> S40 C�ko n C A ti,53W Inspection Date <br /> Time In Time Out <br /> Business Rep__ Title O AM r1 O AM <br /> I ' <br /> S 5 0 P v - QPM <br /> op- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 'r 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l 1 9 Active 0 Passenger 0 Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> * New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> . 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 <br /> A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 1 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 MA / M09 <br /> / <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 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 1 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: § L 1 1 <br /> Comments 11 X01 XX f1Q, U�u��'ts 11 rE� 1 f� - — -D L -G!� � i vo w <br /> S2` Wm-ct�2n�fS f bS.rc1 ---- <br /> Inspection Form Included: <br /> Comments Included: ' — - <br /> B in ss Reps Signature Phone Number Inspec 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect ( - L71® -- - -- - <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py <br /> White Copy:CIWMrt -Py. <br />