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Waste Tire SU nspection Report Number <br /> y & Inspection Report i <br /> ■ State of California ■ <br /> Survey Form - Page 1 I 1 108826'7 <br /> ,gam CIWMB 181(New 04104) - <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: �- % !, ( C C. _!I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> y Lo L� aA t-6 A_�t, <br /> C;- <br /> Street �-­1� I .- I <br /> E <br /> - <br /> �-'� ��l Y1 / <br /> Inspection Date i �/ C <br /> City S talte ZIP Cade Time 1In � Time Out <br /> Business Re 0 PM QPM <br /> P Title 0 AM r 0 AM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> HE— <br /> —� 0 0 Closed 0 Altered <br /> GPS _ __1 0 Hauler 0 Indoor <br /> Latitude <br /> 0 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> II , <br /> Business Type (Fill all that apply) ,•• 'gym <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 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 / 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 94 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments i r[ <br /> ( rCt �C <br /> L j <br /> L f 1111E (.t �i i'z 1 ![�l /1IC I I)� ��Ct� 1 1-.� 1�-t- l—lir I <br /> Cl (-,/)&// ifl"! _�i)� r} z/Ityrr-r! � " _ felt> ?. c, r�, ('1I��r j UC. -- <br /> nI�xo-,d clry <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - <br /> Business Rep's Signature Phone Number Inspectok,s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, _ A"' J"r A t 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />