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Inspection Report Number <br /> Waste Tire Su. ✓ey & Inspection Repor. ■ <br /> •s= State of California I 1 - 1143579 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> A- SurveLf - BLUE OR BLACK INK PEN I <br /> ness Profile Inspection Details — <br /> t PID- � 1 Inspection Type (Fill one) <br /> Site Suffix: . Routine Q Re-inspection Q Referral Q Observation <br /> Local y+, If Referral,choose referral type(Fill one) <br /> Identifier: ��t' 1�, ��lj�� �E� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addresses <br /> -i�lQ CMvRoy-e, Ave. <br /> Inspection Date Lj <br /> n CA 955 6O > v 1 <br /> Time In Time Out <br /> Business Rep0 PM <br /> ,I \ Title p 0O AM i 0 PM 00 AM <br /> r -- 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 /> � � <br /> Q Active Q Passenger I®Generator Q Outdoor <br /> Latitude ® Closed Q Altered Q Hauler Q Indoor Al/ <br /> GPS <br /> p Q Inactive Q Truck <br /> Longitude - Q Planned (a OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> " Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 0 --- - - <br /> 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/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 In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments <br /> �pection Form Included: Q' <br /> l <br /> Comments Included:® / -- Z OQ•� Z -,66 Z <br /> Business Rep' Ignature Phone Number Ins is i ature Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: ` �/I E X t� X411 F E j 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />