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Waste Tire Si & inspection Repospection Report Number <br /> --•-^' State of California <br /> 'r SurveyForm - Page 1 1 7 - 1425225 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t JL( <br /> 10 f 4j jInspection Type (Fill one) <br /> Site Suffix: 1 `` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (it 1 Jlwa U"wl r O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name �) �f Inspected By Inspector <br /> Vu Vt <br /> rj <br /> Physical Address �/ r_:,1 .1 G <br /> r1 <br /> �vy <br /> I /✓ J a 7 I <br /> Street <br /> F„ Inspection Date I � <br /> OA 's o� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM ET O AM <br /> L O PM O Pnl <br /> Operational Status Tire Type Business Role torage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) ill all that apply) <br /> Tire Count (Whole/PT <br /> EL.LL O <br /> Q Active O Passenger Q Generator Outdoor <br /> O ® Closed O Altered <br /> GPS Latitude � . 0 Hauler Indoor <br /> O O Inactive O Truck <br /> Longitude — O Planned OTR O End-Use ontainer <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O <br /> V <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> O Q Other: § <br /> Comments ,{ ,( <br /> ~il('t(A ( \/ h1cA C_ IOSQ(•� <'�luf <br /> ick dna ears Lo-V1 �7cQ <br /> -IQ�,f -Te f D <br /> Inspection Form Included: <br /> Comments Included: '- <br /> 0;Business Rep's Signature Phone Number Inspecto�'' Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X A NI P L 1 7 3 6 Q°1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />