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® Waste Tire Sue0y & Inspection Reportdknspection Report Number <br /> State of California <br /> CIWMB 181(New )California Integrated Waste Management Board Survey Form - Pau e 1 _ 11_..4_. 12 5 7 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ Inspection Type (Fill one) <br /> Site Suffix: 13101 <br /> 5 ) S 1 f Re ins Q p Q Q <br /> Q Routine Re-inspection Referral Observation <br /> LocalQ n ( If Referral,choose referral type(Fill one) <br /> Identifier: <br /> I C�h{0� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> kjUC-S �fn �(OCer` <br /> Physical Address — <br /> ii . <br /> L ...........P ---------------..................... ............. <br /> Inspection Date <br /> F,,7 Time In Time Out <br /> Business Rep Title <br /> ( • OAM 1 T 0 A <br /> O PM J > Q PM <br /> Operational __ _. <br /> p Status Tire Type. Business Role Storage Type <br /> The Count(W)101 }4 TE) (Fill one only) (Fill ll that apply) (Fill all that apply) (Fill all that apply) <br /> � • ' a�'`` 3 Active �} Passengdr Q Generator Q Outdoor <br /> I !O Q Closed Q Altered <br /> GPS Latitude Q Hauler O indoor <br /> 30 Q Inactive Q Truck <br /> ;. ... r <br /> Longitude <br /> g Q End-Use Q Container <br /> I Q Planned Q OTR <br /> Business Type (Fill all that apply) j <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 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 11:1 `/ <br /> IE / El <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 /> 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 <br /> Q In Compliance.- No.Violations <br /> Q Q Other: § <br /> Comments <br /> —1bc J If A �,r., �: 1 : '1 1fl ✓1 �i 1� � I t)j a i <br /> Inspection Form Included: Q <br /> Comments included: Q <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect; { i <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />