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Waste Tire Su ey & Inspection Repor_ Inspection Report Number <br /> il3 State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I - 1088445 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: ` 3 4 ` O • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Sao 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facilit Name 1 t WWW <br /> Inspected By Inspector <br /> �►-�.- o tx,��l ��'gin [� <br /> Physical Address <br /> Inspection Date `,}r� � l 7 � b <br /> \�tnJ Time In Time Out <br /> C <br /> Business Rep Title ' 0 AM fi 0 AM <br /> 1 PM V PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �( • Active 0 Passenger S Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive %Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair o 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 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 <br /> 10 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 DCT) <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 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 10 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators i •In Compliance - No Violations <br /> 0 0 Other § <br /> Comments 1 tyQ� 1 t1S I il, 1 ` >� (- �"IS d <br /> I -n <br /> k0� CAC <br /> �,o Va � bc�s (� GLS c� , <br /> clic c�Ca i� uSe.S--- C.COA 14, 'Cbs v_,�cJ�s� -�i c� rmwj k) • --- -- <br /> Inspection Form Included: 0 60t <br /> Comments Included: 0 `" '�� 83g_1410P <br /> Busines p's Signature Phone Number Inspe is Signature4 one Number <br /> - -- '- <br /> INSTRUCTIONS ON BACK C nicormt. tp V E X A M P LJ EJ 1 2 3 62081 <br /> White Co y:CIWM Yellow Copy:Operator Pink Copy:LEA <br />