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Waste Tire Su► - 4 & Inspection Report Inspection Report Number ■ <br /> F999 State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1143646 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> pection <br /> ill one) <br /> Site Suffix: I Q �? Ins RoutineTyp QFRe-inspection Q Referral O Observation <br /> Local \ �+ If Referral,choose referral type(Fill one) <br /> Identifier: scknJC�Jl�l� <-��1J1'�' 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address J h o mnbi <br /> Inspection Date 3 Q O <br /> Time In Time Out <br /> Business Rep Title / O AM �y Q AM <br /> O PM V �� PM <br /> - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 41 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r L ®Active Q Passenger ® Generator 0 Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O O Inactive 0 Truck <br /> Longitude - 0 Planned Q OTR 0 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 ® Other <br /> i <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 0 1 Other: § <br /> Comments <br /> ULJII , <br /> V, <br /> Inspection Form Included: Q 3 <br /> ZJ <br /> Comments Included: - - - - - � *AW <br /> gn re Phone Number natu Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: A 1 ! 2131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L © 0 <br />