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20WMBWaste Tire Suo & Inspection Report spectionReportNumberState of California <br /> 181(New 04/04) Survey Form - Page 1 Il - 1140823 <br /> California InteCIgrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> r - Inspection Type (Fill one) <br /> Site Suffix: ' ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _Tt , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Fc,.r C,I„i ISI Trt�c t<< ISS 31 - I �-- -'^� <br /> Physical Address O Awtoi ' <br /> Ll 100 !`��;,� Poste . Sle A - - <br /> i Inspection Date Q <br /> s- <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ' ® PM <br /> -- - - <br /> Operational Status I one only) Tire Type Business Role ; Storage Type <br /> Tire Count(Whole/PTE) ( y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger a Generator Q Outdoor <br /> Latitude O i1 Q Closed Q Altered <br /> GPS Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container - <br /> Business Type (Fill all that apply) <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 I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 1 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 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days i (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 1 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: Q �,_nspector', <br /> Comments Included: 2Business eps Signature Phone Number Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ;X A. P 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />