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Inspection Re OInspection Report Number <br /> Waste Tire Survey & p 0 <br /> ■ Iti State of California - 11 1143460 <br /> Pae <br /> CIWMB 181(New 04104) Survey Form Page <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A_Surve _. - __ -- --- -- -- - - - - Inspection Details <br /> Inspection Type (Fill one) <br /> _ -- - - - - - --- <br /> - <br /> Business Profile - <br /> TPID- _ /'� <br /> Site Suffix: 5 3 v ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Shc n JQ G(G U,1 n C(�U{�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busines or Facility Name �,\(, <br /> Inspected By Inspector <br /> Physical Address t ' 0 <br /> a-)Its V), (� (OA tlnt� <br /> � CA <br /> S M Inspection Date�b l Time In Time Out <br /> Business Rep Title O AM O AM <br /> C 5 QPM PM <br /> 3 � Q <br /> �5� fl �� -- ---- Operational Status Tire Type Business Role Storage Type <br /> o / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , I Iv/t <br /> { ®Active % Passenger Generator 0 Outdoor <br /> o 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive ISTruck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply)New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> i V !i A HAULING AND MANIFEST REQUIREMENTS 1 o 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 0 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments J\ <br /> Inspection Form Included: 0'; Joe( $z" SY7 <br /> Comments Included: <br /> iness Rep's Signature Phone Number Inspe�IsSign-tur Phone <br /> J <br /> one Number <br /> -�, 62081 <br /> INSTRUCTIONS ON BACKCorrect: Incorrect. + w!� X A P' L f <br /> White —--- ---— ® ■ <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Co <br />