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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California 11 - 1143953 <br /> CIWM6181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Business Profile - InspectionDetails <br /> BLUE OR BLACK INK PEN <br /> Part A- Surve _ _ _ <br /> TPID- 1 [ Inspection Type (Fill one) <br /> Site Suffix: It u O O J I 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local r--' If Referral,choose referral type(Fill one) <br /> Identifier: Sa� f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> 7eu`n n;c,CA <br /> Physical Address <br /> \Old E• �� i(1..,d . - - -- --- <br /> �a31� Inspection Date 5 � Time <br /> Time In me Outt <br /> Business Rep Title <br /> Q AM AM <br /> I a PM I v v Is PM <br /> - - --- - --- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger IS Generator IQ1 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Inactive Truck <br /> Longitude - 0 Planned 0 OTR End-UseI Q Container <br /> Business Type (Fill all that apply) 1 <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O O <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 /> (Required for NOV or EX7) <br /> 0 0 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 O - _ <br /> 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 <br /> in Compliance - No Violations <br /> 0 0 Other: § --- <br /> Comments tNo <br /> Inspection <br /> - <br /> s�cyu.S_�_fl <br /> Inspection Form Included: Q <br /> ��— w — �"Z1lr -l� I 1�c91J 410 <br /> Comments Included; 1 - <br /> DI &1nspe%>rr'Ts4Signature <br /> (-317jntsss Rep's Si ature Phone Number _ - Phone Number <br /> - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � )C A ,►',J1 P � �, � � � 62081 <br /> ''' <br /> ■ --- - _ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />