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Waste Tire S I w veY p p& Inspection Repo" Inspection Report Number <br /> State of California Il - 1140797 <br /> CIWMB181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey __- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � O 1 Inspection Type (Fill one) <br /> Site Suffix: / I Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SO, Jaw K 1 r\ ( >1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Nixon <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep n Title�+�� O AM O AM <br /> O PM O 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude 0 IS Closed Q Altq�r� pm N��1 <br /> GPS iVV Q Hauler Q Indoor rl <br /> p Q Inactive Q Truc <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Otherf1j J1�i nen-- S�UD <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ENFORCEMENT STATUS <br /> V <br /> l A I HAULING AND MANIFEST REQUIREMENTS P - - - <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ! Date <br /> M / m / m <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 - <br /> - Noy;0 - s "u Le- s a 0C. n. <br /> Inspection Form <br /> �ncluclecl: Q - Q <br /> Comments ncluded: - Cil <br /> Business Rep's Signature Phone Number Inspecto Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:M Incorrect �( �'� X A [7 j 1 i 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:ki <br />