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M j�: Waste Tire Sui .ay & Inspection Report Inspection Repolt Number <br /> �i State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1127674 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: ' 3 - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `n ' n� f If Referral,choose referral type(Fill one) <br /> Identifier: 1� ` V i �'7� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I ?r(_(J),tat <br /> � <br /> Avt <br /> Inspection Date 1 1. 'D / <br /> Time In Time Out <br /> Business Rep Title Ish, 11 44e i 014 0 PM 1 ` � � 0 PM <br /> '�--- Operational Status Tire Type Business RoleStorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> � Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 JENFORCEMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments6a ft' oe� _S <br /> /D C�4-7( �S .s 6�- cone��-q <br /> ,Inspection Form Included: Q �U- <br /> Comments Included: Q fJ/�— —As <br /> -- �b Q � X7477 <br /> Busine epfa—,re Phone Number� in Vi <br /> p c -s gnature Phone Number. <br /> INSTRUCTIONS ON BACK Correct:* incorrect: XV <br /> yje A 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE ® ■ <br />