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J <br /> Waste Tire Sur vey & Inspection Report 'Inspection Report Number ■ <br /> 1L�i= <br /> CState IWMB <br /> of California Surve Form - Page 1 <br /> = CIWMB 181(New nage y g I 1 - 1143533 <br /> California Integrated Waste Management Board <br /> Part A- Survey_- -- BLUE OR BLACK INK PEN <br /> Business Profile TInspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 3 -1 V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: S(,k4 OLl(� LL)n .u.n�' O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - -J - - -- <br /> Business or Facility Name Inspected By Inspector <br /> QS 00� ess V q,\\ Sere cQ,S 9 - 4 <br /> Phys cal Ad ess ' �n Fslwta <br /> Inspection Date O �l I 0 <br /> 1 Time In Time Out <br /> Business Rep Title I 0 AM I % O AM <br /> lO O PM t J O 11111 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 /> ® Active Q Passenger • Generator la Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive IS Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> I i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 10 Other ka4 (aj le-P4111 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> i Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 10 In Compliance - No Violations <br /> O 0 Other: § <br /> Comments1,- 1fl .nom -p <br /> Owl s <br /> N� U ►a��,�-�,It, S Amu c��,,� o� conte, <br /> 'Inspection Form Included: Q' Q / .ems ? r� <br /> Comments Included: 9 -- �-!- SiO - t� ��oq =J� /8 <br /> Bu ess ep s Signature Phone Number Inspe r s Signature Phone Number <br /> INSTRUCTIONS ON BACKCorrect Incorrect: I 62os1 <br /> P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />