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Waste Tire Su & Inspection Report pe <br /> Y ction Report Number p p <br /> State California I .L - <br /> 1127452 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A__Survey <br /> Business Profile Inspection Details - - <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: ® ` � - I * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CL , L%n C�LR1n� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph�4Ae-A ess �Xpnnc�s� L,ne,S 3 9 Rtf) ECAO <br /> - --(-�- --- -- <br /> III <br /> �a,/ Inspection Date <br /> 0(� C, III cw Time In C� Time Out <br /> Business Rep Title * AM � I y 5 AM <br /> Q PM ` Q PM <br /> A\ - <br /> -- - ---- - - - - - — - 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 10 Generator Q Outdoor <br /> - - -- - --- O Q Closed Q Altered "/A <br /> GPS Latitude Q Hauler Q Indoor <br /> i O Q Inactive '� I* 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 ®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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> 00 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 M / M / FT] <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 (D _2a <br /> J <br /> A(LUV- <br /> 71nspectionFormIncluded: <br /> ments Included: Q Bu I ss Rep's Signature Phone Number/ Inspec is Signature Phone Number <br /> - u1 12 3 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: , J X A P <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ® ■ <br /> ■ <br />