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Waste Tire jur & Inspection Repdrspection Report Number ■ <br /> State of Form - Page 1 I 1 - 1127460 <br /> CIWMB 181 CaliforniafNew 04/04) Survey g <br /> California Integrated Waste Management Board a�/ BLUE OR BLACK INK PEN <br /> Part A- Survey - - - - - - - --- - --- <br /> Business Profile Inspection Details <br /> TPID- `` Inspection Type (Fill one) <br /> Site Suffix: L 3 3 V © ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S(IL(I "Jaa. �un Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N. L. <br /> Physical Address 3 V Bn C—,,,& <br /> CA 9 5 3 2 Inspection Date O O <br /> Ec,ca do Time In Time Out <br /> Business Rep Title r O AM J 0 AM <br /> ` J ® PM "1 ® PM <br /> -Stl,nPotcz1y -- -- <br /> -__ � — - V -- C 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 /> Tire Count(Whole/PTE) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> -- --- — --- - ------ — — O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair i Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <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 Q Other <br /> -------- ---- -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> V-1 A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Compliance Deadline <br /> -Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42953 9 � <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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/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 1(1 / <br /> if 4 R- <br /> --na_v <br /> —FO-1 01A AS <br /> i <br /> Inspection Form Included: Q <br /> Comments Included. Q - <br /> -601 %t-31-7e <br /> Busines R 's Signature Phone Number Inspe or's Signature — Phone Number i <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect: Incorrect: � , X� A M i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br /> ■ <br />