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im1% MWaste Tire Su vey & Inspection Report Inspection Report Number <br /> State of California <br /> BI1 - 1143776 <br /> C 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' O 3 0 I i Routine Q Re-inspection Q Referral Q Observation <br /> LocalI ,, If Referral,choose referral type(Fill one) <br /> Identifier: SOLO 16 GI U'l fl W UAAy Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 44 / Inspected By Inspector <br /> G�P �i f�S — �cn CSCOII� <br /> Physical Address 3 <br /> �1q S _ �► r�vr} �w <br /> Inspection Date <br /> Time In Time Out 1 <br /> Business Rep Title I 0 O AM Y S 0 AM <br /> 0 PM <br /> • PM <br /> -- -- - <br /> �— Operational Status Tin: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 ® Passenger ® Generator ® Outdoor <br /> O 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 /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> VA HAULING AND MANIFEST REQUIREMENTS 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 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 EX7) <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 I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In compliance - No Violations <br /> Q Q 1 Other: § rr _11_11__ l <br /> Comments tt.UVt[ri� {h ily� r`foSMOA of\ TV1iS i�W G �� 1016MAN ,0M <br /> tyo ViO,OL`10t1g � a I"" IQC�L n - <br /> Inspection Forrn �nc <br /> ncluded: Q U <br /> Comments luded: ® QCtr—__ �����' — <br /> Busines Rep's Signature Phone Number - is is S_ignature Phone Number <br /> r, <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C A <br />