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--- ----- ---- <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> ■ <br /> State of California J1 1127903 <br /> clWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey - <br /> Business Profile inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: I Lj 0 Jr' 5 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHIP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> UOP 0(A, V1,Ck V1 (f— <br /> Physical Address <br /> Inspection Date <br /> CA Time In Time Out <br /> Business Rep Title 0 AM AM <br /> 0 PM 0 PM <br /> YN� T�kCLO 4 1� Status Tire Type Business Role Storage Type <br /> Operational <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) Cl 0 Active ® Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> GPS Latitude 0 0 inactive 0 Truck 0 End-Use ie container <br /> Longitude 0 Planned OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q 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 Other e– AM� <br /> 'CO CEMENT STATUS <br /> �yNF6 CEMENT E <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility <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 mM <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 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 I& In Compliance No Violations <br /> 010 Other: § <br /> Comments <br /> fi <br /> Inspection Form Included: <br /> Comments Included: * Phone Number <br /> usin Ign re Phone Number In S* nature <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X A Ell' <br /> - -- _._ © ■ <br /> ■ White Copy:CIWMB Yellow Copy:operator Pink Co L <br />