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------- --- -- ... ...... .. .... - --------------- <br /> see <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> state of California Survey Form _ page 1 1127851 <br /> clWMB 181(New 04104) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A_- Survey __ <br /> Business Profile inspection Details <br /> Inspection Type (Fill one) <br /> TPID- 5' <br /> Site Suffix: C) 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> If Referral,choose referral type(Fill one) <br /> Local <br /> Identifier: 0 CHP 0 CIWMB0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By inspector <br /> 'T <br /> CC,Vlej CAZC--,, - <br /> Physic Addrl)ss 9 <br /> Inspection Date -,z <br /> Time In <br /> 0 AM Time Out 0 AM <br /> Business Rep Title LI ®PM ® PM <br /> Business ole Storage Type <br /> Operational Status Tire Type B s,R, <br /> (Fill one only) (Fill all that apply) (Fill all that <br /> apply) (Fill all that apply) <br /> aTB to Role Storage <br /> apply) <br /> (Fill apply) <br /> (Fill, <br /> r 4 3 0 ( <br /> Tire Count(Whole[PTE) 1 3 *Active -4p-passenger 0 Generator I* Outdoor <br /> 0 0 Closed 0 Altered r i <br /> GPS Latitude 0 inactive I*Truck 0 Hauler Indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use_ Q Container <br /> Business Type (Fill all that apply) 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet <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 O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT.STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS I 0 Notice Of Violation 0 Extension <br /> 0 Q <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Compliance Deadline <br /> 0 1 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 PRC§42956-Registration/Decal in Vehicle Requirements Cl <br /> 0 OT14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ------ <br /> 0 i 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in compliance No Violations <br /> 010 Other: § <br /> Comments <br /> -- <br /> Inspection Form Included: <br /> Comm Jrclu igna r Phone Number <br /> Comments Included: osj <br /> ess Rep's Phone Number ns ct s <br /> si 62081 <br /> Correct incorrect: X M 3 <br /> INSTRUCTIONS ON BACK E X <br /> White-Copy:CIWMB yellow Copy:operator Pink Co <br />