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E Waste Tire Su, y & Inspection Report ispettionReportNumber <br /> State California Survey Form - Page 1 I 1 - 1140638 <br /> C <br /> California InteIWMB 181(New 04/04)grated Waste Management Board <br /> Part A- Survey _ BLUE_ OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` S -1 o? fd Q r ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: soon 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> WV <br /> Ph sical Address P�"�, 1rUC/�' �r l - ' <br /> y � � f � 0 / /�%►iZ4M�k ��'�'�n <br /> Inspection Date l /y / / / Q <br /> Time In Time Out <br /> Business Rep Title 0 AM f _ 0 AM <br /> �!v W'�✓��7 UI1� )'YIC�'�1'� _ 1- �,�, � _`j _ ® PM ® PM <br /> 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 /> f / ® Active 0 Passenger (0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto 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 0 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 /> --- - ---- 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 <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 /> I <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> YJA <br /> I -- <br /> Inspection Form Included: 0 <br /> Comments Included: ® - o(�,Z <br /> Business Reps Signature Phone Number Inspector's Signature Phone Number,. <br /> X � 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EX A L EI 12131 <br /> White Copy:CIVVVS Yellow Copy:Operator Pink C y:LE <br />