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a <br /> Waste Tire Su. �y & Inspection Report Inspection Report Number ■ <br /> rill State of California <br /> CIWMB 181 California Integrated Wast(New <br /> Management Board Survey Form - Page 1 Il - 1143659 <br /> Part_A- Survey -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details f <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: o/ 7 <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: saw iYCJcZ h 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> ism - &6, 19r <br /> Inspection Date 7 <br /> JL ,/ 14'5 <br /> Time In Time Out <br /> Business Rep Title / AM 1 AM <br /> 0 PM / 0 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 /> 40 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> i <br /> Business Type (Fill all that apply) a <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder • Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTS TUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FU / M / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ��,2 p� /� ` 4,4,r� <br /> f��� : �CLG-,-G'� ,�` �'� //..JJ � fC�tGt•��''t id/�L�f� '1'�"`�'( , �, G <br /> A0 <br /> Inspection Form Included: Dj <br /> Comments Included: 0 .. •_ -1' - - -- - - _ <br /> Busifj ss Re 's Signa ure Phone Number Inspector's Signature _ Phone Number <br /> - - --- <br /> INSTRUCTIONS ON BASK [Correct 0 Incorrect. X *- �� 1 ' 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />