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Waste Tire Surve ns ection Re O n#ction Report Number <br /> --rii State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1143773 <br /> California Integrated Waste Management Board <br /> Part A- Survey- ..-- -_ - -_--_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- pp 4 Inspection Type (Fill one) <br /> Site Suffix: 1 J `SJ I • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SOl n JpGW1.L1 n G u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> Luc,v.S O 7cu.c�;ny <br /> Physical Address <br /> Inspection Date a 1 l Q <br /> c.12-�o n 5a15 <br /> Time In Time Out <br /> Business Rep TitleI ! AM 1� O AM <br /> V(n� O 0 PM I o'er O O A PM <br /> kot, Vxxce o 0 Wer - - - - — --- - — <br /> --- - - Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �g •Active Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - Q End-Use Container <br /> 9 Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> i Q New Tire Dealer Q Auto Repair 0 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 Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> V q <br /> Q A Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. j 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 / 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 /> QQ - <br /> ' 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 ' I 1 (\ l <br /> �oucyz�5�1.e (vn �eJaTn .rl�10 R -Cn►-J- � <br /> n"irAaV os)s or C rwe s-o�-_c.o(yecn .- - - - - - - <br /> - <br /> bllbk -91L�­ 5J"P6 4-AJAJM1+0 (xs LAM <br /> Inspection Form Included: Q 1-f / S/ <br /> Comments Included: QI - - <br /> �x -�a�� yg.3►�$— <br /> u iness Rep's Signature Phone Number Inspe is Signature -- Phone Number <br /> - - <br /> --- --- --- - - I -- - <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X -' ,_/ 1 C 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:L <br /> ■ <br />