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■ } ; Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> «� State of California 11 - 1143991 <br /> CIWMB181(New04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey___ <br /> - - - - - - - - -- - - <br /> ----- - - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Op Routine Q Re-inspection Q Referral Q Observation <br /> Local /, If Referral,choose referral type(Fill one) <br /> Identifier: be.2Y\ �)C(�1. uw\ 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busine1ss or Facility Name Inspected By Inspector <br /> Physics Address Lr�n1�G�z'l <br /> {� Inspection Date �j 0 / 0 <br /> CA q`��v6- Time In ✓ Time Out <br /> Business Rep Title 0 AMC� / <br /> ' O PM l 3 :J O PM <br /> V�Y� �ZL ���� t1110 ✓- - --- Operational Status Tire Type Business Role Storage Type <br /> — — (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Closed Q Altered � 1A <br /> GPS Latitude W/A Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container— <br /> Business Type (Fill all that apply) <br /> QNew Tire Dealer Q Auto Repair Q 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 ® 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 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 / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 <br /> Xr <br /> 1 D <br /> Inspection Form Included: -7�7t <br /> Comments Included: <br /> Q Busine Re�'S` igna a .- Phone Number I p cto gnait Phone Number <br /> - - -_ ;- 62081 <br /> INSTRUCTIONS ON BACK <br /> Correct:* Incorrect: X "!� A M L I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />