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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> `HOM State California Survey Form - Page 1 Il - 1088039 <br /> CIWMBB 181(New a <br /> California Integrated Waste Management Board <br /> Part A- S u rvey BLUE OR BLACK INK PEN <br /> Business-Profile Inspection Details <br /> TPID- 1 1 O 1 , (/ _ /� Inspection Type (Fill one) <br /> Site Suffix: `�1 t `� Q v ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �'• 1If Referral,choose referral type(Fill one) <br /> Identifier: .. an 5cw_Q"Ul n Co � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 5Ilk <br /> Inspected By Inspector <br /> rn� (`�e.�a1 <br /> Physical Address <br /> lobo S . <br /> (�4o��kv� �� ^G�� Inspection Date � � a � � o <br /> `71 J Time In Time Out <br /> Business Rep Title o O AM O AM <br /> �� mw.Jo Sad aAD A cf ® PM -� O D PM <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 /> - Is Active Q Passenger ®Generator Q Outdoor <br /> �D Q Closed Q Altered "� <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude - Q Planned ® 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® OtherC}�1 CIALI l <br /> v I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility I ENFORCEMENT STATUS <br /> aT ,�ID� „ l=�„S7�RE�R 11� <br /> �� �Q Notice Of Violation �Q Extension <br /> QQ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> jwl <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> i <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 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 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 n ; &OM, 0 <br /> ecN-.cuX \X'0 a•e,A _ v �'T,nJL <br /> im 1vu vxp',n)_ l <br /> cio <br /> Inspection Form Included: Q �OV�j(� J '^ <br />