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<< , Waste Tire A6ey & Inspection Rep" Inspection Report Number <br /> State ClWM f 81(New ) Survey Form - Page 1 19 - 1 0 5 $ 7 9 <br /> CIWMB 181 New 04104 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O / - } Inspection Type (Fill one) <br /> Site Suffix: (� J ®Routine Q Re-inspection Q Referral Q Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: JGI.�` ��Oct L;w_ COL. k, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Ca Se Y ' S �i a�ti�- Ti re <br /> Physical Addrel;s - d <br /> I I D> W, Rot , <br /> L--Uist i CA _ Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> �tl�s• I CLV_S�v1 S ovJ netr <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive if Truck <br /> Longitude _ Q Planned I® OTR Q End-Use Q Container <br /> i <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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder IS Other hawl a gervi cc <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> A HAILING AND'€iV ANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)- Tire Program 10 Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required f4r.NOVOrEXT) <br /> ......-- <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> —..-.....--...... ....__. ------ <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q R9fylTPad I 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 <br /> Q O other: § - In'�otapliarkoo No Violations <br /> —I <br /> Comments Faa U+uj 9d A 6- ictl;f t t-e <br /> <4v(/ice fDr- heetvy t pmeo ' L2Ster Sire Cteyctei- I-tails nc�s <br /> Per m v liA fi- , V jei,,ved at above— No cLf- <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usiness Rep's Signature Phone Number I specto Signature Phone Number <br /> INSTRUCTIONS ON BACK C�tltcttl �E X��+µ 1 tt f 213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />