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Waste Tire Su. . ey & Inspection Report Inspection Report Number <br /> State of California <br /> 02 CIWMB181(New 04104) Survey Foran - Page 1 I 1 - 1143981 <br /> California Integrated Waste Management Board <br /> Part A-Su"ee r _ BLUE OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> y ' <br /> Site Suffix: i / 6 0 9 a C} 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �[ � AC�.�/� C� (�►'l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Bu1sriness or Facility Name Inspected By Inspector <br /> V C Ad���le v ��✓�t'Ylc1 prz) Yl <br /> al ress �� 0 <br /> Physic <br /> Inspection Date <br /> CA 5,366 V <br /> Time In Time Out <br /> Business Rep Title O AM �j 0 AM <br /> ® PM G 0 P <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 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered IVIA <br /> Latitude <br /> GP$ 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 7 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 Pfz*ole Vei7A7-� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 m / 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 1 0 Other: § <br /> Comments <br /> co <br /> Inspection Form Included: 0 l f <br /> Comments Included: ® - --- <br /> __ _ n ep Sig to nil sp ctor' nal e Phone Number <br /> INSTRUCTIONS ON BACK Corr ct: corr : A M p � � r � � 62081 <br /> -- <br /> White Copy. IWM Yellow Copy:Operator Pink Copy:LEA <br />