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I <br /> Waste Tire 4"y & Inspection Rep4%nspection Report Number ■ <br /> EE'sState of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 112 7 7 4 8 <br /> Management Board <br /> California Integrated Waste Manage <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- c-� Inspection Type (Fill one) <br /> Site Suffix: t 6 0 ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ /' L If Referral,choose referral type(Fill one) <br /> Identifier: &a Cc m (�I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A-me_r (_c n �,Sy�- ins <br /> Physical Address 1 / ) f��,Imo'/ gojLL <br /> � <br /> 4' <br /> Inspection Date f / j D <br /> Time In 1 G' Time Out` <br /> Business Rep \ J Title O AM G Q AM <br /> V r �'GL� C� ' . '3 0 PM -- 0 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 /> ® Active Q Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 16 OTR O End-Use Q Container <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 ® Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_— <br /> V <br /> PRC 42951 AND <br /> Tire Hauler Registration and Transport of Tires <br /> VV A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q § 9 p <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> Q Q 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 O 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: § -J <br /> Comments <br /> .5:tkf, FOLIO ' <br /> (,.✓ - - -- <br /> )'InsAla t 1 a �� r.� 0),- <br /> Inspection <br /> pection Form Included: Q <br /> Comments Included: — <br /> Bus�.R.'. Signature Phone Number Ins r' ature Phone Number <br /> --- -- <br /> r�,�, �--� .,,..._ ,,..,T_„_ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � , �/ X P 1 ' 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy:L <br />