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:. Waste Tire Sey & Inspection Repor• Inspection Report Number <br /> "� State of California CIWMB 181(New 04104) survey Form - Page 1 I 1 - 1088179 <br /> California Integrated Waste Management Board Y �7 <br /> Part A. rve BLUE OR BLACK INK PEN <br /> Busines Su • A7J ''•Inspection Details <br /> TPID- Inspection r j Inspection Type (Fill one) <br /> Site Suffix: + L' ( I ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. , n ,1 ,_j <��„�, ;. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address f Cr I I rA�r ) r l� rel A- <br /> (c= ( r 't Ct' C C 1.�. r� tL/(1'it'�r <br /> l - <br /> Street <br /> x A 6" Inspection Date !� <br /> t tc _h) <br /> Crt;, State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> i <br /> .1 1 O PM --�-- O PM <br /> 4/1 r� - <br /> 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/PTE) <br /> �'�-- Q Active Q Passenger i Q Generator Q Outdoor <br /> GPS <br /> Latitude W O ® Closed Q Altered <br /> I Q Hauler Q Indoor <br /> - �O Q Inactive Q Truck <br /> I Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fi l'aI that apply) IL <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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q 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 Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q Q 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 /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ti V <br /> Inspection Form Included: Q W �ij J <br /> Cr <br /> -- <br /> Comments Included: QI . <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: Xj�, V I(r XI R M P L I E i I 12 I � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />