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Waste Tire SA & Inspection Reporis. Inspection Report Number <br /> a® St ateCalifornia SurVe Form - Pa e 1 i - 2568 <br /> CIWMBB181(New 04/04) g - <br /> California Integrated Waste Management Board - - - - - ---- <br /> Part A- Survey - Inspection Details <br /> T " BLUE OR BLACK INK PEN <br /> Business Profile p <br /> TPID- /,� r r- t Inspection Type (Fill one) <br /> Site Suffix: - <br /> QRoutine Q Re-inspection Q Referral Q Observation <br /> Local 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 Address <br /> Street _ I.'-- I I / �.--t_._:_l / �'-- <br /> Inspection Date <br /> e <br /> City ` , c ; .�j � f ,S��•' + I <br /> • 1 ate ZIP Code Time In L-T Time Out _ 0 AM <br /> Business Rep Title1. O PM <br /> 0 PM <br /> 177 <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 1 r t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Cuunt(Whole/PTE) f g 1u„ <br /> is Active Q Passenger ('Generator Q Outdoor <br /> Latitude L fQ Closed Q Altered <br /> GPS Q Hauler <br /> Indoor <br /> tJ Q Inactive Q Truck <br /> Longitude - T Q Planned Q OTR Q End-Use Q Container <br /> Business"I ype (Frll 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 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 Q In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> t d - <br /> 6�i r ,,{ _— 1.,.i', �1 E _ !`I✓�i j. I''/��42•a �i�'. ..�1`/ ( ': <br /> Inspection FormIncluded: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � i;- ,u; ,��"A -" I,_,l: _ _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />