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. Waste Tire Suftly & Inspection Reportelnspection Report Number <br /> State of California <br /> �r is CIWMB 181(New nage) Survey Form - Page 1 I 1 1088144 <br /> California Integrated Waste Management Board g <br /> Part A SurveBLUE OR <br /> ACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> f Site Suffix: y I I U S Z <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: .JG n J-U Ct o n C U`._.ltl <br /> 1 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p y Inspector <br /> Physical Address 3 — /` <br /> Street LO <br /> LZT <br /> ---Inspection Date / / ^[�J'__ _ . <br /> City _-- — State Z/P Cade Time In Time Out <br /> t <br /> Business Rep Title — _ .-., _—. <br /> � 1 O AM O AM. <br /> O PM — ' _T <br /> O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> T ( Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> p--J�— Q Inactive Q Truck <br /> Longitude _ ' r ~� IO <br /> g Q Planned Q OTR O End-Use Q Container <br /> Business Type (Ful all that apply)New Tire Dealer QAuto Repair O Trucking <br /> ng FleetO Government 0 Retreader Q DIsmantler <br /> Q Tire Derived Fuel <br /> i <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 — <br /> I n t-r, <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 /> Q O 11 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> I <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / ELI / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 10 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § ® In Compliance - No Violations <br /> Comments P u.�I t %Y)—, i r1 �] <br /> _ . _L T 1 G9 Yl- —Q�� i 0 r mp- 4,t r.l f ��� 1 r wv—, <br /> 7Lr� E �►1.�f' Ip — i ` Gt1QrQ�fC Du1 �Jy <br /> •_31�rltfa yr <br /> specktoh Dorm <br /> g e.`'° _ Phone Number <br /> ;Comments 1nC)fdd�d; .« <br /> A° Busme , Mme; Phone Number It or's Signattare miter { <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X E X�A�,M9 P I L I L I_ I 1 ; 2!31 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> { <br />