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Waste Tire S eY & Ins Inspection Report Number <br /> Inspection Re p� <br /> ■ 117 State of California ■ <br /> CIWMB 181(New 04104) Survey Form - Page 1 I1 - 1127944 <br /> California Integrated Waste Management Board <br /> PartA--Survey_ -_ -_ BLU_E_ORBLACK INK PEN <br /> Business Profile .Inspection Details <br /> TPID- � � 1 1 1 � � _ O � Inspection Type (Fill one) <br /> Site Suffix: (J ` 4 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical ddres� <br /> �3 <br /> 12: 5 �7a-�erlov (Zd. __ I <br /> g5z5 Inspection Date <br /> n I n I <br /> 5 aL OI <br /> Time In Time Out <br /> Business Rep Title /� AM AM <br /> I d O 0 P ` 0 . 5 s OPM <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 /> yL <br /> 0 Active 40 Passenger ® Generator 46 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive (10 Truck <br /> Q End-Use Q Container <br /> Longitude — Q Planned ® OTR ! <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ! le In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Q1(12. L l l <br /> OVIPIA - <br /> Inspection Form Included: QI (p�j <br /> Comments Included: <br /> Business Reps Signature Phone Number Inspec s Signature Phone Number <br /> INSTRUCTIONS ON BACK ! Correct: Incorrect: �/I it A g' 1 Z13162081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co <br />