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, <br /> Waste Tire Su., - ey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1127716 <br /> California Integrated Waste Management Board <br /> Part A- SurveY--- -_ _-- -- BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- � Q �J - © � Inspection Type (Fill one) <br /> Site Suffix: o ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: scm '�Oc( jun Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l� Inspected By Inspector <br /> Lem> - l <br /> Physical Address I C Q Amu �,•, <br /> 1.717 e,J C c( r CJ <br /> ( / Inspection Date L <br /> � C.SOC V�j 1 lJ <br /> Time In Time Out <br /> Business Rep Title /� O AM (�j r� O AM <br /> Ghuc� so tip\ M&� ® PM `' *PM <br /> -- - -- - — - -- - -- -- - - ------- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active ® Passenger ® Generator Q Outdoor <br /> Q Closed ®Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ®OTR Q End-Use ® 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 /> ®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 J ENFORCEMENT STATUS <br /> —V1--A- I HAULI <br /> -NG---AND—MA---NIFEST---REQUIRE---- --M----ENTS- - --.._.__.. .- - - — ---- - ---- — <br /> � <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 m / m / m <br /> Q 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 DCT) <br /> Q 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or.Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments i <br /> Inspection Form Included: Q <br /> fat q6 s---`'fS7� <br /> Comments Included: 0 -- - --- -- ------- -� - -- - - �'EJB =lfi - b_- - -- <br /> us' ss Rep's Signature Phone Number cto s ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: !� is A P, 1 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:LE ® ■ <br />