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'SSF Waste Tire Si Inspection Reporft:tion Report Number <br /> fill. State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140962 <br /> California Integrated Waste Management Board <br /> PartA- Survey --_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> i Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �y i Mt�krc,�c�s _ <br /> Physitt"ddress 3 L/ Q <br /> C� <br /> - <br /> Inspection Date j 1 Qt j D <br /> S-I-o CAA 9s.�o Z 1 / <br /> Time In Time Out <br /> Business Rep Title 0 AM �• 0 AM <br /> /�' O PM 0 PM <br /> rc.Q --- <br /> / Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f ' i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude <br /> - Q Planned ® OTR Q-- Q - <br /> End-Use Container <br /> Business Type (Fill all that apply) J <br /> Q New Tire Dealer Q Auto Repair Q 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 /> i Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Wkq c SPI,r4-s <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 m / 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 (Re4diredfor 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� t � <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 <br /> O O <br /> Other: § <br /> Comments t <br /> - d)AHV t__-- f r1 <br /> u fav_I_K� W LC-S' kip.�'CG'1- •• <br /> Inspection Form Included: Q <br /> Comments Included: 0 -� Pep'�s <br /> -- - - - - - — -- - - - - - <br /> BusinessSignature Phone Number Inspector's Sign a Phone Number <br /> INSTRUCTIONS ON BACK Carredt _X AIy 1 , 2 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:LEA <br />