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.y & Inspection Report Inspection Report Number <br /> Waste Tire Su_ <br /> � -� State of California <br /> -or CIWMB 181(New04104) Survey Form - Page 1 I 1 - 1141237 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile 4, Inspection Details <br /> NNW <br /> TPID- I j1 j O Inspection Type (Fill one) <br /> Site Suffix: ;v) Routine Q Re-inspection Q Referral Q Observation <br /> I� <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: U �(�(� ul n ���� � O CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> Business or FaciliW Name Inspected By Inspector <br /> Physical Address 1 I v <br /> Street <br /> 17 . <br /> Inspection Date <br /> 11 7_1 <br /> Ciiy StateZiF Cade Time In Time Out U <br /> Business Rep Title , 1 ; /11 0 AM 0 AM <br /> O PML <br /> O PM <br /> ........ _...__ Ll..... _�.-1�J ._..-.... Operational Status Tire Type Business Role Storage Type <br /> ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/P'TE) <br /> ®Active Q Passenger O Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude i ,[ € <br /> Q Hauler Q Indoor <br /> D Q Inactive Truck <br /> f.—.. <br /> Longitude – Q Planned O OTR O 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 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler (1)Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- -- -- ----- --- Q Notice Of Violation 0 Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> a, Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 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 O In Compliance - No Violations <br /> O 0 Other: § <br /> Comments _ __..__ ___._;•___ .__.-...____.._____..._F - <br /> C bArc. <br /> Inspection Form Included: Q <br /> Comments Included: Q -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E LL X iA Mi 1 2 i 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />