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i <br /> Waste i a Sury <br /> State of California * Inspection Re ort . ,pectionRe ortNumber CIWMB 181(New 04/0 ■Survey Form - Page 1 I - 1 1 9 4 4 3 <br /> California Integrated Waste Manage nt Board <br /> art A-Survey <br /> usiness Profile — - BLUE OR BLACK INK PEN <br /> Inspection Details <br /> 'PID- <br /> ;Ite Suffix: - Inspection Type (Fill one) <br /> -3 � � a i <br /> -T <br /> Routine 0 Re-inspection Referral { <br /> ocal 0 Observation <br /> lentifier: S If Referral,choose referral type(Fill one) <br /> - —11�—"- 0 CHP 0 CIWMB <br /> usiness or Facility Name Complaint Q Educational Visit Q Other <br /> Inspected By Inspector <br /> �c�. <br /> iysical Address 3 C/ <br /> H u��_�� ?�h ��3�� Inspection Date / 2- 7- <br /> / <br /> isiness Rep Title Time In Time Out <br /> OAM 0A <br /> VVX"AA PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ire Count (Whole/PTE) �( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator 0 Outdoor <br /> PS Latitude O 0 Closed 0 Altered <br /> O 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> siness Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Truckin Fleet '- <br /> 9 0 Government 0 Retreader Dismantler - <br /> 0 Q Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> t B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Extension <br /> 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 PRC§42956-Registration/Decal in Vehicle j Compliance Deadline <br /> 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB Date <br /> 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years --- <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0. <br /> 0 Referred <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities !CIWMB Enforcement <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> D Other: § ® In Compliance - N <br /> P o Violations <br /> tments - <br /> �-��r i:�►c-per cam. � .� _ - - <br /> cbc� <br /> 44 <br /> 12� d Cf J7 I - �-}� /1J' "�"]✓►�1 (� l ��is _. 1 <br /> tion Form Included: 0 <br /> omments Included: 0 y(i}�^0(v Z <br /> _ Business Rep's Signature Phone Number spector's Signature <br /> Phone Number 1 <br /> INSTRUCTIONS ON BACK " oriiec Incorrec62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA `' <br />