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' Waste Tire S&*y & Inspection Repo Inspection Report Number <br /> L!ii State of California <br /> i1_ CIWMB181(New 04/04) Survey Form - Page 1 I - 1 Q 7 d 1 <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 /> 5 0 <br /> Site Suffix: p� V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � �� /' If Referral,choose referral type(Fill one) <br /> Identifier: e -FJVY1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S 16 P 7-_6 <br /> Physical Address ' 1 <br /> 60 <br /> � <br /> Inspection Date <br /> ve �� t yr l 64- 675z20 <br /> Time In Time Out <br /> Business Rep Title GAM / AM <br /> ® ® O PM ! O 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 /> 0 Active Q Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR 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 /> 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 A HAULING AND MANIFEST REQUIREMENTS 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 /> 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 /> --- - -- - ------ <br /> Q Q - - <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 f 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 S In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Aye <br /> Inspection Form Included: Q a <br /> g _-b 2 Ak)G . <br /> Comments Included: Q ,- -- - --40 <br /> - — -- <br /> Bu roes s ature Phone Number In a nature Phone Number <br /> - - - -- ---- - - 62081 <br /> INSTRUCTIONS ON AC orrect: Incorrect: (, (� E X A P r 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pin Copy: <br />