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== Waste Tire Sur - Jy & Inspection Report Inspection Report Number ■ <br /> ill9 State of California 11 - 1143464 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part_A-_Survey . - - - - - <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f � � q � � � _ 0 � Inspection Type (Fill one) <br /> Site Suffix: L l Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ r ,,]. If Referral,choose referral type(Fill one) <br /> Identifier: ��n oo.�u�n �Ou Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 1 ven �szo��0 <br /> � N)Q- <br /> nspection <br /> Dv� �/tA ��xs IDate � � ti 5 <br /> C) <br /> Time In Time Out <br /> Business Rep Title ` O AM O AM <br /> \� ``,,,, I 2 <br /> Cu,A r�2 �L'Lrit✓l n1L. J ® PM O PM <br /> - - -- Operational Status Tire Type Business Role Storage Type <br /> O (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 /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler Indoor <br /> 0 Q Inactive 1*Truck <br /> Longitude - Q Planned Q OTR o End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair IS 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> o Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> o Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> o 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> o 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 Other: § <br /> Comments D �_�1`fl. i f c—� ` �A C1 —��—� �5 A' <br /> Inspection Form Included: <br /> Comments Included: 40 7,06 <br /> ®,Bu' sines RfSignature Phone Number Inspec 's Signatur Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X M I ` 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop "LE__._ ® ■ <br />