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JoInspection Report NumberWaste Tire Surlby & Inspection Report <br /> State of California 1 .� — �+ <br /> 85�.8w3 CIWMB181(New04/04) Survey Form - Page 1 ai - r <br /> California !- <br /> Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Aw Inspection Details <br /> TPID- } Inspection Type (Fill one) <br /> Site Suffix: . , % l✓' f L'� Q Routine O Re-inspection 0 Referral O Observation <br /> Locali t If Referral,choose referral type(Fill one) <br /> Identifier: � {a� 4i1! 'I t j j,d �1 l/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> . fin <br /> Inspected <br /> f By— <br /> Inspector <br /> _U12 I/ 1t, UG71 <br /> PhysicalAddress- T <br /> Street Inspection Date <br /> ��I i� f <br /> � �� �r"l C�`T � L� ���.�,'�� <br /> State Z/h Code Time In _^ Time Out _ <br /> Business Rep Title O AM Q AM <br /> -T, s O PM - Q PM <br /> Fill one only) Fill all that apply): Business Role Storage Type` <br /> Operational Status Tire Type <br /> Tire Count(Whole/PTE) ( y) ( pp y)'', (Fill all that apply) (Fill all that apply) <br /> O Active Q Passenger O Generator 0 Outdoor <br /> Latitude <br /> O Closed 0 Altered <br /> GPS Q Hauler 0 Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude — Q Planned OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler D Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> 0 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 /> — 0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB i <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ---- <br /> O O 14 CCR§18459.3 Retention of Comprehensive Trip Logs for 3 years <br /> - - ---- --- - --- <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 0 0 Other: § — -- <br /> Commentsl,� ( r( /�[��lt/ <br /> 0 , _ct C� b_ `. l Cdr <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - -= - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X - 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />