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Waste Tire Sufty & Inspection ReporteRnspection Report Number <br /> CIWMBB181(New 04104) <br /> State of Survey Form - Page 1 1 3 - 10 7 9 4 16 <br /> ' A- Survey California Integrated Waste Management Board <br /> art BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G Inspection Type (Fill one) <br /> Site Suffix: 3 44 -l 01 4) Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,YL � t/��11 (�,'(J1� -'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> Physical Address l d lIJU rJj�jt�(� <br /> CAS�D� Inspection Date <br /> t t7� l <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> j 1 J 60b I- 4aWf 0 PM � L� � ®PM <br /> `"r 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 /> Is Active Q Passenger *Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 F m / m <br /> Q 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 (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 I&In Compliance - No Violations <br /> Q Q Other: § <br /> Comments r <br /> U <br /> Inspection Form Included: Q e <br /> Comments Included: — — Cy- -�� 7 3 <br /> B ess R `s gnature Phone Number In tor' i lure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: lT' I M i E/41 , 131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :L &A 0 <br />