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Waste Tire �ey & Inspection Re AbInspection Report Number <br /> �i18� State of California p ■ <br /> I= CIWMB181(New 04/04) Survey Form - Page 1 I1 - 1143819 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> � TPID- � e , � � � � �y - o Inspection Type (Fill one) <br /> Site Suffix: 1•` `11 IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalejOCV� <br /> if Referral,choose referral type(Fill one) <br /> Identifier: S(An u1 �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> co(ks CoAl►SiOrN ov -cam 3 <br /> Physical Address <br /> alb30 N40 PIa16., <br /> tA �� Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM ? 0 AM <br /> , f Lim n PM J a PM <br /> - <br /> - - - - - - --- — - — -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered j NSA <br /> GPS ! 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 1 0 End-Use 0 Container <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 /> 0 Used Tire Dealer S Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> j 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations <br /> 0 0 Other: § <br /> Comments Ofrlcrvv fiU-1='-L'DWn WSJ!''-i- f. <br /> ;�ob ions T CUM <br /> 4 <br /> Inspection Form Included: 011 <br /> Comments Included: 0 4�� - <br /> Busine p s S r Phone Number Msir hone Number <br /> INSTRUCTIONS ON SACK Correct Incorrect XI l;Inspe <br /> X I 62081 <br /> ---- <br /> �- <br /> ■ White Copy:CIWMB Yellow Copy:Operator ) Pi k Co ■ <br />