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Waste TireY & Inspection�e Ins Re C7��o Inspection Report Number <br /> p p <br /> CIWMB 811i0 <br /> (New04104) Paig <br /> SurVe Form - e 1 I1 - 1143814 <br /> California Integrated Waste Management Board Y J <br /> Part_A_--Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � _ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (,t, 50CkAW1 n �o� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - -- -- <br /> Business or Facility Name Inspected By Inspector <br /> T�a('A (ASO 3 _ } o <br /> Physical Addr s 1 EsLAto <br /> tou.1\ Av "" <br /> CInspection Date <br /> Il(_I Time In Time Out <br /> Business Rep Title 1 h 10 AM 1 /`� Q AM <br /> �_.. ll 1 V Q PM 1 lJ ® PM <br /> rN <br /> - - - - - - - -- - — Operational Status Tire Type Business Role Storage Type <br /> t <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> x.11 <br /> Active 10 Passenger S Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler IS Indoor <br /> O Q Inactive ® Truck <br /> Rude - <br /> g Q Planned ® OTR i Q End-Use Q Container <br /> Lon <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Is 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 Other SC601 r31 s�r1 uk F f It�c-i <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 <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 ® 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 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 /> Q Q Other: § <br /> CommentsCA 11 hi <br /> - ` <br /> CDS t, <br /> Inspection Form Included: QI 2-, <br /> Comments Included: �l -- ��'g� "�l� ��i`-pVW CdVIJ�VU^3��� <br /> Bu ttess Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Co :L ■ <br />