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Waste Tire Sup Bey & Inspection ReportState Inspection Report Number ■ <br /> CIWMB181(New Survey Form - Page 1 <br /> CIWMB 181(New 04104) J ��iiy g Il - 1143772 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Sgrvey -- -- - - --- _..— - - -- <br /> Business Profile Inspection Details <br /> _ _ - -- - <br /> TPID- r. Inspection Type (Fill one) <br /> Site Suffix: D J 1 y 0 Routine Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: — LA" COLA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name AAdrldV <br /> Inspected By Inspector <br /> Physical Ad �1- 'V 9 - t 0 � �) � I►G�►'Y) CI�� <br /> 31103 'r_' . Mc q --- — <br /> Inspection Date <br /> Time In Time Out `J <br /> Business Rep Title7 <br /> t l G 5' O PM J O ®PM <br /> `�e� 001Y161.1-" "6� Operational Status Tire Type Business Role Storage Type <br /> ii (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) l Q <br /> Active Passenger, ® Generator • Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O - 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR End Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer •Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or DC7) <br /> 0 0 <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: ® - - <br /> B iness Rep's Si ature Phone Number ( IVi�'lj ree Phone Number <br /> �� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: k N_/ � P� i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink o ® ■ <br />