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:'3. <br /> Waste Tire Su. :y & Inspection Reporglnspection Report Number <br /> :rr State of California S u rVe Form - Page 1 Il - 1127662 <br /> CIWMB 181(New 04104) y ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey____ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 r Inspection Type (Fill one) <br /> Site Suffix: 1 �.J �j t� 0 t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: \> r tom( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> _� <br /> Inspected By Inspector <br /> Physical <br /> iAddress RXQ:CA �C� <br /> Inspection Date I <br /> Time In Time Out <br /> Business RRepj� Title <br /> 6 AM Q ®AM <br /> CJ�[✓ fluS��j �'J's'�.�� / � � � QPM QPM <br /> -- --- -t----- --------- - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck � <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer JkAuto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other d y 0� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use-Facility ENFORCEMENT STATUS <br /> ------- —-------------- <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 1 0 Other: § <br /> Comments - <br /> 1a�t-c� no <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - -- r - ?Z 7-3 <br /> Business Rep's Signature Phone Number I e t r gnature Phone Number <br /> - -- - - - _ <br /> INSTRUCTIONS ON BACK Correct_ Incorrect: ( X A M ! 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />