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09210040250 <br /> r== Waste Tire Survey. & Inspection Report Inspection Report Number <br /> een_ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form -Page 1 � 1 $ - 10 7 9 3 5 4 <br /> California integrated Waste Management Board <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 I I I�� Mot <br /> ®Routine Q Re-inspection. Q Referral Q Observation <br /> Local �- 1 If Referral,choose referral type(Fill one) .. <br /> Identifier: QCHP QCIWMB QComplaint Q <br /> Educational Visit <br /> Q Other <br /> Bus' ess or Facility Name J Inspected By Inspector <br /> I - <br /> Physical Ad ess 3 1 1 l L& <br /> a%9 JA <br /> Street <br /> Inspection Date OF V <br /> City n State ZIP Code Time In Time Out <br /> Business Rep Title ® ' `^ 5 PM0 AM <br /> � ' O ® PM <br /> Operational Status Tire Type Business Role .Storage Type <br /> Tire Count(Whole/PTE) { ��j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Generator ® Outdoor <br /> I Active Passen <br /> ge <br /> Latitude0 Closed Q Altered Hauler. Q indoorGPS �— — —I <br /> _— Q Inactive Q Truck <br /> —I� I O <br /> Longitude - I ��- Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) 111 111 111 <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 6 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B- Inspection.of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 In Compliance - No Violations <br /> Q Q Other: § '1 '' 11 nn <br /> Comments � � rOn- -a�) -- —- - ` - W <br /> �s <br /> Nei— ai—��� . _ �'Lw121�Z;rL <br /> Inspection Form Included: Q <br /> Comments Included: Q — <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor ect: I orrect: ( l +� 62081 X A M P l E' 1 Z 3 <br /> White Cop CIW Yellow Copy Operator Pink Copy.LEA <br />