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L3a� <br /> Waste Tire Su. y & Inspection Report aspection Report Number <br /> Stateof California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140983 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � Inspection Type (Fill one) <br /> Site Suffix: � _ U ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1;UVY-1 ti 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> c- c S <br /> Physical!AddressCA � <br /> 739 6- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> Q AM Q AM <br /> f QPM © I ® PM <br /> —C_ — — 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 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 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 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 1 0 Notice Of Violation 0 Extension <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 Date mm / m <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 /> 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 /> 00 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 /> — - -- r` C.1y,,r —)tt <br /> Inspection Form Included: OI 1 <br /> Comments Included: - wi� - �Pe�ct'Ps <br /> ���/ �--�� r2� Ypa� <br /> P <br /> Business s Signature Phone Number ature Phone Number <br /> ------ --- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ,. X�A'�i P � �� 111273 <br /> 62081 <br /> White Copy:CIbW013 Yellow Copy:Operator Pink Copy:LEA 12 <br />