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Waste Tire Sl. way & Inspection Repoi Inspection Report Number <br /> eiii�. <br /> State of California <br /> L& Survey Form - Page 1 ( 4 - 0 7 9 1 6 9 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ? / 2 / Inspection Type (Fill one) <br /> Site Suffix: J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SyC,N �•4�.u�iv �urJ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> V TSr - l d l <br /> Physical Address VL HA y9[' ` <br /> yyZ /J, �4%�o'f-T- <br /> �� i� 1520Inspection Date 3 2 <br /> Time In Time Out v <br /> Business Rep Title /- Q AM Q AM <br /> O PM QPM <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 /> S <br /> ® Active 9 Passenger ® Generator i Outdoor <br /> 0 O Closed O Altered <br /> GPS Latitude � 0 Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture O Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HA U <br /> ONG ANRWWX <br /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ----- --- - - --.----- ------------- ._ <br /> ..__ <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> A)J <br /> - <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Bus] s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIX p L 23 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />