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==eek Waste Tire Survey & Inspection Report _ Inspection Report Number <br /> State of Californla _ _ _0 7 3 4 8 6 <br /> CtWMB181(NeW04/04) Survey Form - Page 1 1 5 1 <br /> California Integrated Waste Management Board BLUE OR Bt-ACK INK PEN <br /> Part A- Survey __- <br /> Business Profile Inspection Details <br /> TPID- ') Inspection Type (Fill one) <br /> Site Suffix: I ® 13 I J 3 f' .3 Q , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - <br /> 10 <br /> - <br /> .S <br /> Inspection DateCIA <br /> r ;,: Time In Time Out <br /> Business Rep Title j -- --I j O AM -- j - _ --� AM <br /> O PM � � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill <br /> p1 all that apply) <br /> Tire Count(Whole/PTE) N <br /> •Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS .Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> - - <br /> Business Type (Fill all that apply) _ - t(-f J <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel 11 <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 10 Other L- i I --Z hnawt� `X� <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 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 f 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 1 Other: §�} <br /> Comments <br /> T-A- Z4 <br /> -- 1rr r-1�,.�'H mtn--Qn—plc c cam -1_11-f--r-7-7 a te. _�i✓IS_or,_ j <br /> Inspection Form �nc <br /> ncluded: O <br /> /°6 g –06 2 3 <br /> Comments luded: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect:X4 V 0 XhA A P L E 111213 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />