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Waste Tire '*0 ey & Inspection Repoh 0, Inspection Report Number ■ <br /> State of California I 1 - 1140923 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q /� 1 Inspection Type (Fill one) <br /> Site Suffix: , (Q d ` �/ 1 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sao0 �,� �n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v <br /> Inspected By Inspector <br /> �` R1:-� V�� , enc, 1 - a <br /> Physical Address 3 ,` .N 1 E. Z'go <br /> M �oJw�fl 57- <br /> CA <br /> Inspection Date r a <br /> �, Time In Time Out 1 <br /> Business Rep Title /�'� ��ll O AM U o 0 0 AM <br /> V V ® PM 1 �J V ®PM <br /> �tcuc�0 4 o , fi�aa c_ -- - ----- - - --- <br /> -- -1-- -- --- ----- +-- ---/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l,� 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I* Active ® Passenger Generator ® Outdoor <br /> O 0 Closed �Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive ®Truck <br /> Longitude - End-Use Container <br /> 0 Planned ® OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> VO Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V-1 A HAULING AND MANIFEST REQUIREMENTS 46 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date r <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __ <br /> 14 CCR§18462-Manemequremen <br /> Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 0 In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments �" 1 <br /> 1� <br /> Cam, �DT <br /> Inspection Form Included: ® rr.. 011le Y7O l VII <br /> Comments Included: ® i(4p�J gW317-o <br /> Bu lines, p's Signature Phone Number Inspec s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X I v E j i 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />