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Waste Tire Sup vey & Inspection ReporlOnspection Report Number <br /> State of California 1143503CIWMB 181(New 04/04) Survey Form - Page 1 I1 <br /> - <br /> California Integrated Waste Management Board <br /> Part A- Survey - . - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: l 5 q 1 5 � I 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local *� If Referral,choose referral type(Fill one) <br /> Identifier: SG(e) J octG t o n (OLA/nl� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ---- - - - - l - -- -- - - <br /> Business or Facility Name l Inspected By Inspector <br /> butCkC) b �' sc.S �VlcrJ15 �( _ 1 <br /> Physical Address 1 ` �e(� <br /> X-7 1AA <br /> (� � Inspection Date <br /> 6 - " ('D "A %ao 1" Time In Time Out {{{ <br /> Business Rep Title0 AM 0 AM <br /> ` <br /> Q 1 i ' )_ 5 ® PM ® PM <br /> O y7u l�Ia- 5x.�2.0 Vi S b f I - - -- _ - -- - ----- - <br /> -- - - -- - - - - -- ---- Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) 1 1 r7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> s "1 ( 4) Active Passenger 0 Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 1 Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business 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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> 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 O <br /> 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 i 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 \ 1 I <br /> e. 0 cYl J — <br /> jinspection Form Included: QI <br /> � Comments Included: 6� -�� ---�---/�- <br /> Business Rep's Signature Phone Number I4's ignature one Number <br /> - - -- - -- - <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect "Y A M P` f 2 3 <br /> ■ WhiteCopy:CIWMB- lWMB C - - - ® ■ <br /> Yellow Copy:Operator Pink ColkL <br />