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`= a� Waste Tire S►... . �y & Inspection Repo, rispection Report Number ■ <br /> State of California 11 - 1143608 <br /> CIWMB 181(New <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey_--___ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection, � � � � - o � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Sm, -h -yvcK <br /> Physical4dress 1 G ' 4( 14yztt2IoLli <br /> , <br /> Inspection Date 3 l <br /> Time In Time Out <br /> Business Rep Title O AM ®AM <br /> I --J' Operational Status Tire Type Business Role Storage Type <br /> / <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger Is Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive � ®Truck � <br /> Longitude - 0 End Use ® Container <br /> 0 Planned 0 OTR <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 flob-i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> PRC§42956-Registration/DecalposE in Vehicle <br /> 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements ' Date <br /> 0 0 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 /> 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 01 <br /> D � <br /> Comments Included: ® - - --.. - _ `t �6C�-`G'6 7� - -- <br /> Business Rep's Signature Phone Number ec s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect Ir ,i it A P� -i 1112 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cot, <br /> o y:LE ® ■ <br />