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= Waste Tire Su y Lx Inspection Report T,nsl,-,;tion Report Number ■ <br /> State B California Survey Form Page 1 i 1 - 1143554 <br /> CIWMB 181(New nage) V � Y y g <br /> California Integrated Waste Management Board <br /> Survey <br /> - - _- - - - - Inspection - BLUE-OR BLACK INK PEN <br /> [Business .i <br /> T' PID. Inspection Type (Fill one) <br /> Site Suffix: $ 1 5 I I• Routine Q Re-inspection Q Referral Q Observation <br /> Local e , If Referral,choose referral type(Fill one) <br /> Identifier: Si,an J (�a(�1 A Cent Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> ,�1 Inspected By Inspector <br /> f G �� a�5 l it i 11Te.n�0(A-- p <br /> Physical Addrre�s - O I &n &CO�'('71 <br /> Inspection Date 5 I 0 <br /> Time In Time Out <br /> Business Rep Title � AM AM <br /> I � � I, <br /> n �1 I& PM Q �® PM <br /> a, Su v;stir -- - --- - - - - <br /> - ------ - - - -- -- - -- G ` --- Operational StatusT Tire Type Business Role Storage Type <br /> J -- <br /> ' <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I.� <br /> Active Passenger ® Generator Q Outdoor <br /> Latitude <br /> D Q Closed I*Altered <br /> GPS Q Hauler i Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 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 /> VT A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 m / m / m <br /> Q 1 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 <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 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 1 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance - No Violations <br /> 010 Other: § <br /> IN <br /> ^ ,U r� dl <br /> Comments - 1 -U*r n2� � 2�4-�sv + ) - - - -U � 11� j�,' � <br /> _'-- <br /> N , 11 �� S u f cel S 0& u)-(l(,f n- - -- <br /> Inspection Form Included: Q y " \ <br /> Comments Included: u �� /�(� !t- J00VIV37 <br /> Busi ess Rep's Sign t re Phone Number Inspect s Signature ne Number <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect X E ?t l f 2131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C p . ■ <br />