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M Waste Tire Su. _ ey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1127928 <br /> Management Board <br /> California Integrated Waste Manage <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- .�j 2 _ O 1 Inspection Type (Fill one - Q - - Q - - <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1�al A erg l �e,Y v��-e. '��c�c,(,M� ' c,- - 1 D <br /> Physical Address <br /> } Ct5a06 <br /> Inspection Date <br /> me c <br /> Time In Time Out <br /> 0 AM <br /> Business Rep Title ^' O AM Q O 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 /> 1 —70 ®Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 0 Othere}=L� �Pf yc <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 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 /> Q O 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form �nC�Uded: O e�•�y� �/�j� <br /> Comments ncuded: ® Cr --- — ----- - /'zCr—e_ r6I S <br /> Business Rep's Signature - - Phone Number rl tor' ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct: incorrect. <br /> }� / ; a 4 � <br /> -- - - ® <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L M <br />