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Waste Tire Su&y & Inspection Rep®rtilD Inspection Report Number <br /> State of California �p �yy <br /> CIWMB 181(New 04104) S u r�L a °"o r�1 1 �a e 1 Z — 1141191 <br /> California Integrated Waste Management Board Y g <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , } <br /> ..._ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /^ If Referral,choose referral type(Fill one) <br /> Identifier: �(,� 1. 'A, C (�Tl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address , t r [ 1 <br /> .. <br /> s;e�t <br /> Inspection Date <br /> V,,tc Timeln Time Out <br /> _Prate ZIP Code <br /> Business Rep Title i I 0 AM 0 AM <br /> 0PMe ... . 1..i OPM <br /> t.rlkl�ti �1c � ..... <br /> } Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (fill all that apply, <br /> TireCount(Whole/PTEA <br /> ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered I GPS Latitude ' i�_.�..�.i � �_, � 0 Hauler 0 indoor <br /> __. I_.. I _ O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 t)I R1 0 End-Use 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 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber r 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other %f <br /> s <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> — --- 0 Notice Of Violation 0 Extension <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 0 in Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ji�, � i­, .� A ,llrO,. 62081,� ����� <br /> ® White Copy:CIWMB Yeliow Copy:Operator Pink Copy LEA <br />