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a spection Report Number <br /> Waste Tire S & Inspection�Rep0 <br /> ■<' E&i State of California <br /> MIS CIWMB 181(New 04104) Survey. Form -•Page 1 ''. Il 1.088086. <br /> CaIifornia.lntegrated Waste Mariagement Board <br />�. Part A'- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �J Q 11) <br /> Inspection Type (Fillone) <br /> Site Suffix: 1 T � Routine Q Re-inspection Q Referral Q Observation <br /> Local ( I If Referral,choose referral type(Fill one) <br /> Identifier: �(� 1 � � .0o \U ,�i� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I Inspected By Inspector +: <br /> fa <br /> ! <br /> Physical Add ess ; — vW'd <br /> 't.)+ i I <br /> Street ` FITl l <br /> A�oni �l Inspection Date <br /> :G 0 J, __j <br /> city '—% State ZIP Code Time In Time Out <br /> Business Rep Title 0AM ( 0 AM <br /> 1 FW : 0 PM :� QPM <br /> Operational Status Tire Type I 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 /> r ` Q Active O Passenger @ Generator Q Outdoor <br /> QClosed Q Altered <br /> GPS Latitude m . Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — TE Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 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 (g) Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V : A 'HAULING AND MANIFEST REQUIREMENTS <br /> Q I Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q_ PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q I Q PRC§42956-Registration/Decal in Vehicle <br /> Q I Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl / m / m <br /> Q i.Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 114 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 .i 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 j <br /> Q Q Other: § <br /> Comments <br /> l.1 (u�.' c, -)': <br /> Inspection Form Included: Q <br /> Comments Included. b!._A r- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ._-- � <br /> INSTRUCTIONS ON BACK'I Correct:* Incorrect: ' FM P , P <br /> a;. <br /> e White Copy:CIWMB- Yellow Copy:Operator Pink Copy:LEA`l ■ <br />