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Waste Tire SJty & Inspection Report Inspection Report Number ■ <br /> State of California Il - 1143822 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A__Survey _--_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � n _ � � Inspection Type (Fill one) <br /> Site Suffix: d (6 Routine Q Re-inspection Q Referral Q Observation <br /> Localv1� � �•,, If Referral,choose referral type(Fill one) <br /> Identifier: �' I Sq J 1 - l)1�n, `,\UJB Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical dress &o-h <br /> 5A"S \kkf� WC(\ <br /> nspection Date <br /> SI j <br /> \_S I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> PM � 5 � PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger 41 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive • Truck <br /> Longitude - Q Planned (10OTR Q End Use Q Container <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 /> IQ Service Station Q Hauler Agriculture Q Shredder ® Other F( "O)C 1 kLA01-I �qu;?MK6 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> i Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 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 O - - <br /> 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: § <br /> Comments �1�t"C��-1- {0� p�'�US_C��,I�Q�— ►� e--G�,�I�.�Y ISL--=��UW](t(�_�� t�lcQ� <br /> Inspection Form Included: Q .� i>J �� IComments Included: Q -.Suslnes ep's Signatu a �1 .21�� Ins'ec s Signature - one Number <br /> - - - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect1 X -- 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C&E ® ■ <br />