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Waste Tire S ey & Inspection Repo Inspection Report Number ■ <br /> State of California I 1 - 1127896 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA- Survey-_ 1. - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Ct j * Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: ScolJtl�tlll,M IC,/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> V <br /> Business or Facility Name + Inspected By Inspector <br /> Arme <br /> Physical ddress aC� �CcL ( t�,��G � � <br /> �� C Inspection Date <br /> Cti 1.�(t..� (�`� `1/�93 -7 l l <br /> Time In Time Out <br /> Business Rep Title O AM _J r/ O AM <br /> PM T- 0 PM <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 /> f ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler O Indoor <br /> O Q Inactive it �Truck <br /> Longitude — Planned OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O Q 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 /> O 0 Other: § -- - -— <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® 35' <br /> B si ess Rep's Signature Phone Number I s ig ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect. X k, %/ ) �� I 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />