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Waste Tir! ;urvay & Inspection Relrt Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I1 - 1140001 <br /> California Integrated Waste Management Board <br /> Part A-Survey --- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 0 Iq © I ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> �7 <br /> Identifier: e%A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name li Inspected By Inspector <br /> Physical Address <br /> Inspection Date 1 1 j <br /> L._ C;f 1 Q5�4l o l I CEJ <br /> Time In Time Out <br /> Business Rep Title 2 . � 5- 0 PM <br /> 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 /> 9 41 Active Q Passenger Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 Q 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 ®Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS l <br /> V A 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q QQ Referred/CIWMB Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q, <br /> Comments Included: ® - I�GIs lj_- � l.K.+'__ - --- , - —'c -QGS/� <br /> Business Rep's Signature Phone Number V tor' S' nature- Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. >V1 � }( <br /> ! l A �_ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C ■1 ' 3 62081 <br /> -- - -- - --- - -=— ®op <br />