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■ i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California 11 - 1143593 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey - <br /> ,mess Profile I Inspection Details <br /> TPID- ` f,� f,, i Inspection Type (Fill one) <br /> Site Suffix: 1 5 CQ lV lY ® I * Routine Q Re-inspection Q Referral Q Observation <br /> Local r- If Referral,choose referral type(Fill one) <br /> Identifier: f1JML LLA r) � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected By Inspector <br /> c.Cc.o.. E� P c n� o 1�e n ESco�O <br /> Physical Address <br /> �03o �- E . � i xon � � -t- -- - <br /> ,.�'`A q5a� Inspection Date <br /> S' a ,R / Time Out <br /> CA Time In i <br /> Business Rep Title O AM I0 AM <br /> M 0 41 PM PM <br /> C�e_ - - cfa- sqptAOperational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 3 7 16 <br /> Q Active ® Passenger ® Generator Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive �Truck <br /> Longitude - Q Planned p OTR Q End Use Q Container <br /> siness Type (Fill all that apply) _.-. <br /> New Tire Dealer Q Auto Repair Q 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 I_ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other i J�(� P,(1rl�Le SY1U <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS_ _ <br /> V I A I 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 m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q I (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> OQ 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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 of MA O_V_ -CSW` —C.,A_ --�`--- - <br /> NO <br /> Inspection Form Include ZBusine <br /> � <br /> Comments included. -- - -- - <br /> p's Signature _ Phone Number - Inspe or's Signature Phone Number <br /> - - - - - - -- — X 1�' I E I j- <br /> White <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: ( ) � � � � (- � � r <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ■ <br />