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Waste Tire Su. <br /> itey & Inspection Repoi . Inspection Report Number ■ <br /> „p State B California I 1 - 1144039 <br /> CIWMB 181(New 04104) y - Page 1 <br /> California Integrated Waste Management Board Survey rV a Form <br /> BLUE OR BLACK INK PEN <br /> -t A-SurvPY_ <br /> ,iness Profile Inspection Details <br /> PID- Inspection Type (Fill one) <br /> Site Suffix: —1 ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �)t �1_�v�, Cci11Yl `�/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — l Inspected By Inspector <br /> VIC <br /> Physics dress <br /> 704 Ze-VVIy Y �t <br /> CA Z.�!�uL/6 Inspection Date I l <br /> Time In Time Out <br /> Business Rep Title ) !�AM O AM <br /> _ ] \\ l QPM <br /> l SCD<� L-)Y1CJ,5� LEZcV lln/`G L Z ®PM <br /> — -- —-- Operational Status Tire Type r(F�ilslallness Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) that apply) (Fill all that apply) <br /> f Q Active Q Passenger Generator Q Outdoor <br /> O ® Closed Q Altered i <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 <br /> Q Q - (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> 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 /> 00 Other: § <br /> Comments <br /> �pection Form Included: Q <br /> Comments Included: I® — - - -n - <br /> B si Signature hone Number In ct is Si a re Phone Number <br /> -- - - - <br /> INSTRUCTIONS ON BA f rrect Incorrect i r� p Ei 1 ; 3 62081 <br /> ■ White C B Yellow Copy:Operator Pink Copy:LEA <br />