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Inspection Report Number <br /> � <br /> Waste Tire Su0 ,ey � Inspection Reportp p T 1 <br /> � '- State of California 1 1 1141187 <br /> CIWMB181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> S e Suffix � �. .. 1 i l Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: Q �C �1 cuu V _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address LEI <br /> _91L, <br /> P . ;� { <br /> >mm �X1`1��...__, s <br /> 4'��_��_ ____ _ ___ __ _�'�_-________ .__ - �---;--•�_ <br /> Street <br /> f Inspection Date �'� 1 141... Time, Tlme InTime Out <br /> °o<e _ <br /> Business Rep Title , I �- 0 AM 0 AM <br /> ^� <br /> 0PM OP <br /> M <br /> '"....... .' __""" �`"" " "' Operational Status Tire Type Business Role Storage Type <br /> ype <br /> Tire COUnt{ $101e/ TE� i i { (Fill one only) (Fill all that apply) (Fill all that apply) (rill all ghat apply) <br /> �. Q Active Q Passenger Q Generator Q Outdoor <br /> — )D Q Closed Q Atere <br /> d <br /> Q Hauler Q Indoor <br /> GQ Inactive Q Truck <br /> D <br /> Longitude - Q Planned L OTR <br /> Q End-Use container <br /> c!' <br /> Business'Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q _ - Q Notice Of Violation Q Extension <br /> 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 1 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 0 In compliance - No Violations <br /> Q Q Other: <br /> Comments i }j <br /> inspection Form Included: Q, <br /> Comme;,ts Included: Q' <br /> Business Rep's Signature Phone Number t.3spert.or°s5ignatui•e t=liorx: Nz.isnuar <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X -1�14' \/ 1 Vit; ' € m"_1 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />