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Waste Tire Asy & Inspection Repo*nspection Report Number <br /> ® ti:"< ■ <br /> !D3 State California <br /> CIWMBB 181(New 04/04) Survey Form - Page 1 Il 1127904 <br /> California Integrated Waste Management Board <br /> Part A—Survey- - _ _ _- BLUEOR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix:_ `7 _l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C7 /�_ If Referral,choose referral type(Fill one) <br /> Identifier: �JG\i� SnGI�•�V �� —f7',/vli 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 111 <br /> \ Inspected By Inspector <br /> Physical Address ` © /4�fG7L�>/7ncmUlc,` <br /> Inspection Date <br /> ® 1-ave <br /> CA �t dt�� <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> ' © !PM • PM <br /> — - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 40 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> L <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> 00 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> -- ---- ---- <br /> Inspection Form Included: 0 ��/, <br /> Comments Included: ® --- - 0� '3dy—6�q7 — C�/ 67-� <br /> usiness Rep's Signature Phone Number Inc tor' _ignature Phone Number <br /> INSTRUCTIONS ON BACK rCorrect * incorrect X ,*, l: X A 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop(.L © ■ <br />