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Waste Tire Su, ,ey & Inspection Report Inspection Report Number ■ <br /> ,FFIi State of California <br /> CIWMB 181(New 04104) survey Form - Page 1 I 1 - 1127722 <br /> California Integrated Waste Management Board J J <br /> Part A. Surv_ev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: I #I Routine Q Re-inspection Q Referral Q Observation <br /> Local '.'`` , If Referral,choose referral type(Fill one) <br /> Identifier: S(.1{� V C)���i n CUM fl� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1AQ_w+�k ��I5nflf\t4 Se1`Vi CX, <br /> Physical Address 3 <br /> GA y`� v-1c Inspection Date I ? pl Q <br /> Time In Time Out� <br /> Business Rep 1 TitleC. O AM S O AM 4 1 � � t4 � ® PM -� � J 0 PM <br /> J ------ _ Cc_ y�. hi <br /> Fill one only) Fill all that apply) Fill all that apply) Storage Type <br /> Operational Status Tire Type Business Role <br /> Tire Count(Whole/PTE) ( ( pp y) ( pp y) (Fill all that apply) <br /> �D 4'Active If Passenger S Generator I* Outdoor j <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer *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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O O 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O !I 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ! ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments (j �1_ Ln�n-,�.i[� � .. _� ► t��1� -C/� �� UIIV�'ll(� yG1,� nU�C,(i� r <br /> _(l(7 V d a eon 5 (9f (Je cu-t O C.c,�tQrn <br /> 0 Ok C- acs"�c i.-C ug+ate.; r "'L( _ <br /> Inspection Form Included: <br /> p O' <br /> Comments Included: 0!-- <br /> (1-041 --_ <br /> Bu ne el: s Signature Phone Number Inspe is ' nature hone Number <br /> - -- — ---- <br /> 62081 <br /> INSTRUCTIONS ON B CK Correct:* Incorrect J f r P. 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: A <br />