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�, Inspection Report Number <br /> Waste Tire "';0ey R& Inspection Repo* <br /> ."I'm State of California <br /> ' CIWMB 181(New04/04) Survey Form - Page 1 Il - 1143804 <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: t v l '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �M�Ltl <br /> ��,� tf Referral,choose referral type(Fill one) <br /> Identifier: SCkn (� 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �) �) 4 <br /> Physical Address &'n CSCQ b <br /> (,A 45 33'7 Inspection Date I "_7 <br /> Time In Time Out V <br /> Business Rep TitleA AM ® AM <br /> S d O PM ` �/ O PM <br /> 1 �a <br /> -- -- -- - - -- - Operational Status Tire Type (Fill all that apply) Storage Type <br /> Business Role <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger • Generator Q Outdoor <br /> D Q Closed Q Altered Iv <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) Fpr <br /> Q New Tire Dealer Q Auto Repair 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 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 /> 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 <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB FF1 <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 ® In Compliance - No Violations <br /> Q Q (Other: § <br /> Comments 1_ i\ 1(1. Lt_(� �Ct��C.�Qn���S 6Qi G�Y1f11� L0 W0 <br /> - <br /> All 1. <br /> Inspection Form Included: Q <br /> Comments Included: Q - �� /�— <br /> Business Rep's ignature Phone Number Insp or's Signature Phone Number <br /> - - - -- - -_ - - - -. _. -- - --- - - <br /> � 62081 <br /> INSTRUCTIONS ON BACK � Correct:* Incorrect: X � E: A^ F W 1T2� <br /> I---- --- -- --I— ----._ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:L ■ <br />