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0 Waste Tirelu� Y pe & Inspection Re Inspection Report Number <br /> k2CIWMB <br /> State of California <br /> I1 1127459 <br /> 181(New04/04) 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- <br /> Site Suffix: © Inspection Type (Fill one) <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Localr- 1 If Referral,choose referral type(Fill one) <br /> Identifier: Is6k� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l— Inspected By Inspector <br /> Physical Addres �S (7 <br /> q 0`4 Cr,,,,r�r1P�L1� <br /> �L �n 1 Q ^ �531x Inspection Date O y q <br /> 7 wl'\ lJ Time In Time Out 1 <br /> Business Rep Title /y f, 0 AM 0 AM <br /> d� J O PM 0 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 /> DS @. Active Q Passenger * Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler • Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •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 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 <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 EXT) <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/CIWMB Enforcement <br /> Q Q 14 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: § <br /> Comments l 1 1meAp r ` <br /> !Inspection Form Included: Q �;A <br /> Comments Included: Q - -- - -- - - ---- -- --- <br /> Busines ep's Signature Phone Number k1nspepor:, Signature Pone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect: ( k 1#4 L I V I t I 213 620811 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cy: <br /> :LE <br />