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ns ection Report Number Tire SuRly & Inspection Report <br /> M <br /> w.iEagi. State of California <br /> . CIWMB181(New04104) Survey Form - Page 1 11 1088258 <br /> California Integrated Waste Management Board ! -- - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Easiness Profile.; i spe -- LL <br /> n coon Details „ <br /> ' TPID- / Inspection Type (Fill one <br />}' Site Suffix 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �" � If Referral,choose referral type(Fill one) <br /> Identifier: J�! r.� �/ c)�n - �Y Ca a�.1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> qq <br /> t/✓t��a�� _dre �, /� <br /> Physical /Xdss %, . ! _ ) o I _fLt^C <br /> Street f _ -� / Inspection Date <br /> y� _z So <br /> I_ T��' C",4 J <br /> --` �_._._.._.�_. �--�—`-' Tlme In _ Time Out <br /> Stale iii- Code; <br /> Rep Title I 0 AM AM <br /> Business Re <br /> - `l �0PM OPM <br /> N <br /> r <br /> G <br /> --y Operational Status Trre *, Business Role Storage Type <br /> Fill Active �I PasF (Fill( Gener tori I101u doors pl ) <br /> The COUtIt VUltole/pTE ( one Y) � #?�Y) ll PP Y) � f� Y <br /> o , <br /> Fil <br /> Latitude Q Closed <br /> GPS "� Q Hauler Q,lndoor <br /> �J !!! <br /> O Q Inactive <br /> Longitude ` 9 Q Planned Q OTF Q End Use Q Container <br /> (( r I <br /> Business Type (Fill ail that appiy)'' <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 <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 /> - - - - <br /> V A ,HAULING AND MANIFEST REQUIREMENTS <br /> 10 Notice Of Violation Q Extension <br /> Q <br /> 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 /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§1 . - re Program Number �� <br /> M / M <br /> Q Q 84591 TiPID NbfCIWMB . <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 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 O 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1 - <br /> t .1 �'cr <br /> Comments Included: Q, - ' , <br /> '• �� „`77: <br /> ,Inspection Form Included: QBusiness Reps Signature Phone Number (1e�c,tor's'SiEr + `'r+ ,• m r „�,. <br /> p g ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: A 7 7 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ILA <br />