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Waste Tire Suri & Inspection Report .rispection Report Number <br /> �t1 State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1140702 <br /> California Integrated Waste Management Board <br /> Part A- Survey_-_–_ _ --_ _ _ -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /\ 1 If Referral,choose referral type(Fill one) <br /> Identifier: say) '3 Uj�,Gt LAI!� �1A Y) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 4 Inspected By Inspector <br /> er Li ne,S LLC, <br /> Physicalfdldrls 3 1 - o ) CSC,QT`�0 <br /> Inspection Date <br /> UA1 1r,1 Time In Time Out <br /> Business Re--p Title O AM O AM <br /> `M c,AL �AckoAe-` ar"rOTC Sr��t[ �l0 ® PM � 1 5 O PM <br /> - ---- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3 o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t 40 Active 0 Passenger Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude a Hauler ® 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 0 Auto Repair le 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 &Hauler 0 Agriculture 0 Shredder 0 Other <br /> - ----. ----- --- - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ --- — <br /> V A I 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 FF / m / 17 <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 f 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 0 Other: § tom,. <br /> Comments �� !n`Je� "�1�f 1 ( ��1L1�� .� 0�1�' 11_ V `t"f�1 +-6., <br /> un-can <br /> n <br /> Inspection Form Included: 0� y L rip <br /> Comments Included: ® � Number <br /> -- -` - - - A����6�� /r- <br /> Business Reps Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 'X ( X A'lil4 L t2]3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C A <br />