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== = Waste Tire SL. itey & Inspection Repoi Inspection"Report Number ■ <br /> a� <br /> State B California I 1 - 1127856 <br /> CIWMB181(New 041114) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey _- -_ -_ - - _ _ -- -_ - ___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> L <br /> Identifier: ! ^xy\ t�(;(_�G:�a1� �1 11 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I`A�c� �,c�,�,� �Ft�,��,�, Tom. � c1 - l d t t <br /> Physical ddress "- A _ <br /> `, /� �^� Inspection Date 1 i ? () / } <br /> l <br /> Lam,- "yv CA Q �� <br /> 1 Time In Time Out <br /> Business Rep Title f ®AM O AM <br /> 1 J O PM �I C� IIIIII,PM <br /> ra(6) Avo kcs stop Tore�� - - -- —-- <br /> Operational Status Tire Type 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 /> Active • Passenger ®Generator &Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive !Truck <br /> Longitude – Q Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 0 Agriculture Q Shredder Q 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 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance No Violations <br /> 1010 Other: § <br /> Comments <br /> Inspection Form Included: !� <br /> CommentsIncluded: ® In ctor' i ature Phone Number <br /> Business ep's Signa re hone Number <br /> INSTRUCTIONS ON BACK Correct * Incorrect , , ; E , 62081 <br /> ---- - __ <br /> - - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy © ■ <br />