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Waste Tire fty & Inspection RepJAW"lnspection Report Number ■ <br /> ■ IIIIII State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 11 - 1140921 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> !PID- ` � � �J � � _ p+� I Inspection Type (Fill one) li <br /> Site Suffix: ` "� U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �' ` If Referral,choose referral type(Fill one) <br /> Identifier: ov� Jol�yu,l j� C�,�,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> SBusiness or Facility Name —1 Inspected By Inspector <br /> CQ-CkP <br /> Physical Ad ress � ��[ <br /> PInspection Date <br /> _Di0ALVtin c R ` 5an(� 1 s <br /> Time In Time Out <br /> Business Title Q O AM f 0 0 AM <br /> ® PM - 1 V ® PM <br /> I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> ^ O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d <br /> 10 Active ® Passenger ® Generator I* Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Container <br /> Q Planned Q OTR <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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 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 0 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 /> 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 114 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: § w <br /> Comments ti t t f <br /> �a u,�a �i n5 ,Or% DAA3TrQCA 6(7\4 ]5 dlA k9w 41) j))A._ <br /> b 1_c�w � n—oL�► � - <br /> Inspection Form Included: Q Z� Lp , <br /> w-a nts��9_k Q, < ll II !� S <br /> Comments Included: --- —� 6 P9 - �_- <br /> ®;Busin ss Rep's Signature Phone Number nsp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* fq �_ P , a 3 62081 <br /> _ �C _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C A ® 0 <br />