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----- <br /> v---.------------------.__ <br /> e TireWey & Inspection <br /> on Re s" Inspection Report NumberWast <br /> Stateof California I 1 1127877 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> califomia 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: �i 6 f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /` ,L, If Referral,choose referral type(Fill one) <br /> Identifier: ScLiv .�Yl C�rif/1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address <br /> Inspection Date ` / a I / 6 <br /> �(� l <br /> LCA l rx;Ip C A q'�0 Time In Time Out <br /> Business Rep Title ��^^ AM AM <br /> ,, �} <br /> V � V Q PM ' I 0 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 /> Tire Count(Whole/PTE) <br /> Active J9 Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR I Q 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 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 to Other ,Ln L).k- I -InC <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 11,ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <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/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 <br /> in Compliance - No Violations <br /> Q Q Other: § -_.... <br /> Comments <br /> Inspection Form Included: Qt� q <br /> Comments Included: ® �U���-7.3 <br /> - - - -- - <br /> Business Rep's Signature Phone Number n ct 's ig ature Phone Number <br /> — - -- - � 62081 <br /> INSTRUCTIONS ON BACK I�, Correct:* Incorrect. � � A, 12 3 © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />