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=„ Waste Tire y & Inspection Rep Inspection Report Number ■ <br />State of California T m 1127713 <br />CIWMB 181 (Now 04104) Survey Form - Page 1 <br />' A - Survey_California Integrated Waste Management Board <br />art BLUE OR BLACK INK PEN <br />_ <br />Business Profile Inspection Details <br />TPID -� � � � � O � - � � IlRoutine <br />pection Type (Fill one) <br />Site Suffix: Q Re -inspection Q Referral Q Observation <br />Local (//1 If Referral, choose referral type (Fill one) <br />Identifier: Sqn dQ(,I,a ul' it � `�0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name L JJ Inspected By Inspector <br />'�Jro&+0(l �ukp ��SMkn1 �ef_S <br />Physical Address v ® ��� Scab <br />S, el Ncjo <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />95wj Inspection Date <br />/ <br />O '1 / 1 V <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Time In <br />O <br />Time Out <br />Business Rep <br />Title <br />p <br />` <br />*AM <br />Q AM <br />v V <br />Lk <br />f C'i5�Jill <br />QPM <br />PM <br />- <br />O <br />Operational Status <br />Tire Type <br />Business Role Storage Type <br />Tire Count (Whole/PTE) <br />O <br />q (Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />® Active <br />Passenger <br />® Generator O Outdoor <br />O <br />O <br />O O Closed <br />O Altered <br />_I �1 <br />GPS Latitude <br />O Hauler e Indoor <br />O O Inactive <br />Q Truck <br />Longitude - <br />O Planned <br />Q OTR <br />O End -Use �Q Container <br />Business Type (Fill all that apply) <br />- <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Dismantler O Tire Derived Fuel <br />0 Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />0 Agriculture <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />FAULI l- AND MANIFEST REQUIREMENTS <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />O <br />Other: § <br />Comments 0 _% A i _ 1 .. _Lf A _n -Vln! <br />_I �1 <br />" 1 Fu( i <br />ENFORCEMENT STATUS <br />O Notice Of Violation O Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />O Referred / CIWMB Enforcement <br />® In Compliance - No Violations <br />Inspection Form included: Q y�QQ <br />Comments Included: Q - - 414 ' <br />Business Rep's Sign ture Phone Number _ Inspec 's Sign <br />INSTRUCTIONS ON BACK Correct: incorrect: \ -Z `W E: X A P L <br />■ White Copy: CIWMB Yellow Copy: Operator Pink fpy: <br />-- <br />one Number <br />62081 <br />