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€ ` Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 811 State of California 11 - 1143685 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey -- -- -- - - ---- - -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' I "1 l9 0 1 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local ^ tIf Referral,choose referral type(Fill one) <br /> Identifier: S� J Oul^ `Oun� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C04' ('o W` kLk-' _ -f, s� C "n�tCr _ 0 L en z o <br /> Physical Address <br /> C� '5slr7 Inspection Date , <br /> o Time In Time Out <br /> Business Rep Title ' ,^ U C0 AM� AM <br /> V 1 J O PM Q PM <br /> - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 8 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Generator Outdoor <br /> Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® 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 Other C)o t Gj <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 Notice Of Violation Q Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 11 <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 / m <br /> Q Q 114 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> i (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 1 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 ®In Compliance - No Violations <br /> 0 Q Other: § 1 1 <br /> Comments 1 CGl1�ol�tj �� ltUC13�1 "� I-l�- ���i �- T �9 �� �-5- - <br /> - - <br /> - `�_ J ave �►i o\ --- � (Lie-CiALS (.b�1CaCr� (,U_f WI•a U� <br /> Inspection Form Included: 01 <br /> Comments Included: Q - <br /> B ine R p's ign ure Phone Number Inspe is Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK 1 Correct:* Incorrect: X : , �X A M P( �I E 3 <br /> White— — — -- Copy: <br /> _-- —- ® ■ <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />