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■ is== Waste Tire Sum Jey & Inspection Report Inspection Report Number ■ <br /> State of California I 1 - 1143838 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA-Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details j <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �1 b , le Routine Q Re-inspection Q Referral Q Observation <br /> Local `^,, If Referral,choose referral type(Fill one) <br /> Identifier: \n, l Jt-ALJ` 1� G '� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Z7e'l 9 <br /> Physical Address ( lm'✓ <br /> 701 <br /> �� � Inspection Date � � l 610 <br /> I�i:�7L]�-2�CrJ. Time In Time Out <br /> Business Rep Title <br /> p 0 AM �J AM <br /> 6 0 `--�� � 0 P ( C QPM <br /> """' L�sxw Mq - Operational Status Tire Type Business Role Storage Type <br /> --- <br /> f�/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) � � r({,/�'J <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude 1 <br /> Q Hauler Q Indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned Q OTR O 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 O 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 ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 EXT) <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 /> 0 0 Other: § / Y� C —r ---- - <br /> Comments Q 0 l �'G�j If�YY}'1 `71'1/S fa. /ham AD&CcJ�- <br /> kcf I!% 3,2s. - oo 6 , 6JACA �L <br /> V10r —I(ncz td <br /> ,Inspection Form Included: Q AXA <br /> Comments Included: QBu ' e e Signature Phone Numbernature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ICorrect:� Incorrect: ' 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />