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Waste Tire Su, .ay & Inspection Report Inspection Report Number ■ <br /> ii337 State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 114- 3997 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 Inspection Type (Fill one) <br /> Site Suffix: 5 $ V� 1 4b Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: 4(� JoC�,�jU11 n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 - <br /> Inspected By Inspector <br /> Physical Addre &`J E 5tO)h <br /> Inspection Date S V <br /> V aU� �,� 5�o'y <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 40,(-\ �O S �Rr La.fQ 0 PM O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I q <br /> 1 ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 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 /> Q New 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 • 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 /> 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 <br /> � M� o <br /> • 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 (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 /> i Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q 1 Q Other: § 11--`` l <br /> Comments 1�, A(10 )C6 ion (�l V&11 S C. C��1(� hQ � V 1A 1�UWA'nl UM n CA c.1 <br /> nMt6'6_ u CA <br /> Inspection Form Included: O <br /> Comments Included: <br /> --in <br /> - -- `1 � <br /> Bu In— e ' nature Phone Number �Ispe_�is Signature _- Phone Number <br /> _- --- �-_ �_ ✓ 62081 <br /> INSTRUCTIONS ON BACK orrect. Incorrect: , �/! 7 r hA 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />