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Waste Tire Sui .ay & Inspection Report Inspection Report Number ■ <br /> State of California I - 1127739 <br /> CIWM13181(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- Inspection Type (Fill one) <br /> Site Suffix: ` 3 lJ a Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: J(k4 J OW)n coul)kA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �. ,,�` �ran5p�s�a��on 3 - 4 0 ( �n ERGO <br /> Physlca Addres 1 <br /> CA n �l+/✓��J/ <br /> 5 _r Inspection Date I a Q Q "1 <br /> I <br /> `IbTime In Time Out I <br /> Business Rep Title 0 AM O AM <br /> ' 0 PM 10 PM <br /> Operational Status Tire Type Business Role Storaje Type <br /> Tire Count(Whole/PTE) <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger • Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> C Q Inactive I*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 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 /> Q QQ 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. I Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q ' 0 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 (Required for NOV or EXTJ <br /> Q 0 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 1L12� ln_(N_�zAG i��6S4)II S <br /> fin_ OT -u.jums O� -c-0n0Sf\ - - -AD-- <br /> Inspection <br /> Form Included: Q f9 — <br /> Comments Included: (�oJ9 H(A <br /> -— -- — - — --- <br /> Business Rep's Si nature Phone Number Inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK � Correct i �� Incorrect. <br /> White Copy:CIWMB Yellow Copy:Operator Pink op y A <br />