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damn Waste Tire S & Inspection Repor ispection Report Number <br /> State CIWMB California y g I 1 - 112 7 5 7 8 <br /> grated 1st(New04104) U rVe Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A--Survey-- _ BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / 3 I �J l I I&Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: pct c' ty� C�(qj Q CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> 5W- <br /> Business or Facility Name Inspected By Inspector <br /> ILA-T 0 111f fo C*--f C7� <br /> Physical Addres 3 - — / <br /> L S <br /> Inspection Date �� � � 6 J <br /> � � Jl <br /> v, Time In Time OutV <br /> Business Rep Title `� ® AM ®AM <br /> SkpeA/< J D ,-�D QPM l l �T S O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) P (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)', <br /> f D ® Active ® Passenger ® Generator % Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — <br /> 9� Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet ® Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V1 A I HAULING AND MANIFEST REQUIREMENTS <br /> "�''�� ^'� •^° �� <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 � 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> I <br /> 0 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 ® In Compliance - No Violations <br /> 0 (Other: § /� <br /> Comments � rl e 11,0fe.S J_ col' v R&i/, <br /> ' <br /> ee /,AraPinom I�� � &r0c� cisS E C,. 1111IRiurs-7'`� <br /> I <br /> ,)rrvi Syl�c4'0^ C �'c `T�'10I s -I 5 33 13 �'l t�ti- ►Nla i��eS� �v M s <br /> No �llpf. i�t �ti - <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Bus i s Rep's ignature Phone Number Inspector's gnature —Phone Number <br /> -- — - <br /> 62081 <br /> INSTRUCTIONS ON BACK Co`4ect: Incorrect: X ' �A€h�6)P � 2 3 <br /> White Copy:(,IVVMB Yellow Copy:Operator Pink Copy:LEA �� <br />