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■ <br /> Waste Tire Su&y & Inspection Repori_Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I1 - 1141186 <br /> California Integrated Waste Management Board J --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 I Inspection Type (Fill one) <br /> Site Suffixl5 L9 <br /> _ + 0 Routine 0 Re-inspection <br /> Q Referral Q Observation <br /> If Referral,choose referral type one <br /> Local yp (Fill ) <br /> Identifier: A �k i (U\AIA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityNameInspected By Inspector <br /> ,/l t n <br /> Physical Address J I '�4 r, <br /> L -- <br /> Je'zrf�tiaI 3 <br /> Inspection Date , ri i <br /> I <br /> --- — """ Time In Time Out <br /> Business Rep Title j '� ( ANl 4 AM <br /> O PM _ ._ _ ,.. O PM <br /> .I.............._� <br /> perational StatusTlre Type Business Role Storage"type <br /> , O(Fill one only) (Fillall.hat app y) (Fill all that apply) (Fill all that ap <br /> p <br /> y)? <br /> Tire Count( hole°PT ) <br /> i ®Active 0 Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Tuck <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 O 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 Q Other ;�, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS i <br /> V A HAULING AND MANIFEST REQUIREMENTS Q 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 M / Ffl / M Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateQ Q14 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 /> Loo <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> QIOther: § - <br /> Comments �l 11 o. <br /> '° 03,1 U i _ <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number lnspoctor's Signature Phone Nuimber <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I',, A, ,'�' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />