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Waste Tire Survey & Inspection Repos L Inspection Report Number <br /> State of-IHH fornia <br /> CIWMB 181(New04/04) Survey Form - Page 1 Il - 1127908 <br /> California Integrated Waste Management Board <br /> Part A- Surv_ey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � C '� _ © � Inspection Type (Fill one) <br /> Site Suffix: J ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(�{� J Q�u 1Jl �WIA4) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 21 l i � 's f ams tido Nf.. _ I <br /> Physical Address <br /> r C A J301 Inspection Date 1 I 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I 3 0 PM ✓ 0 PM <br /> Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active 0 Passenger 4P Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive � Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto'Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments �eLG.— LSITl��— e� Vf- c�(\ <br /> COLI (an -- - -- <br /> Inspection Form �nc,ncluded: <br /> Comments uded: ® y� <br /> B slnin ess Reps Signatu Phone Number Inspe or s Signature _ Phone Number � <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. ' / Em A M U" V Z <br /> ® White Copy: 62081 <br /> ■ <br /> CIWMB Yellow Copy:Operator Pink Cop :LE <br />