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Waste Tire Sui . vy & Inspection Report Inspection Report Number ■ <br /> State of California I 1 1088434 <br /> i CIWMB181(New 04/04) Survey Fora, - Page 1 <br /> caiifomia Integrated Waste Management Board <br /> - BLUE OR BLACK INK PEN <br /> Part ASurvey_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 4-1 Q _ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � � lJ Cevy/� }'Z Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Sao.c<,-, At,�o Ce aAc r _ ,�►\\ / <br /> Physical Address <br /> alto P�c� G Avg - - - <br /> Inspection Date l / C5bc_� GA Q0_1 - <br /> Time In Time Out <br /> Business Rep Title / _ Q) AM 0 AM <br /> t)(2kf r Pf )fm(W, '"'b CeA�i �a 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 /> Tire Count (Whole/PTE) � � <br /> ® Active ® Passenger O Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) -- <br /> ® New Tire Dealer Auto Repair p Trucking Fleet p 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 <br /> 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 <br /> Q 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 O 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 i 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 c <br /> Inspection Form Included: Q �� <br /> Comments Included: <br /> Busine Rep' Signature Phone Number I p ctd s ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X � V] E- ? 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />