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tti Waste Tire Su, _ ay & Inspection Report Inspection Report Number ■ <br /> LState of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1143598 <br /> California Integrated Waste Management Board <br /> "Art A-Survey BLUE OR BLACK INK PEN <br /> Aness Profile Inspection Details <br /> .rID_ _ Q I Inspection Type (Fill one) <br /> Site Suffix: e Routine Q Re-inspection Q Referral Q Observation <br /> Local ) �r� If Referral,choose referral type(Fill one) <br /> Identifier: �kty),Soaxt�.1.�1) Cole Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physica Ad ress <br /> �LY� V� c A �5 atrs Inspection Date <br /> C)C�� <br /> Time In Time Out l <br /> Business Rep Title 11 11 0 AM Q AM <br /> t {wl t b ® PM - --- - PM <br /> 1 <br /> -Q��`C._ _.. �C� 1(14nU4� 1► - --�5— 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 /> f f Q Active Q Passenger 40 Generator Q Outdoor <br /> O • Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned o OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) (� <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> IQV 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Q 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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments * 1 r 1 <br /> 4CA <br /> ,ection Form Included: Qi G , <br /> Comments Included:�I � p 3 9 Z C✓d`�""' C�`�' , —i� <br /> Bu ness R 4W ignature Phone Number Insp or's Signature Phone Number- <br /> - <br /> / � 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect V )t P (, 1112' 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />