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M Waste Tire Sul .ey .A Inspection Repo In action Report Number ■ <br /> >;= State of California I 1 - 1141045 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: :� 1 I o C t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� /'_. ,,, If Referral,choose referral type(Fill one) <br /> Identifier: � (_.0-�l/Y 1, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ccal l Address j-�'z�v►�`M`-� � �?—i�C' <br /> PhysicSj 9 <br /> A ress �J <br /> (rolc\�evt <br /> Inspection Date 04 � f ) •? � I li-� <br /> CA q�2c <br /> Time In Time Out <br /> Business Rep �/�{ O M Title ' � � A ` zy � O AM <br /> w <br /> • u �z - - I - ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �j " (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •yvj Q Active Q Passenger ID Generator Q Outdoor <br /> O ®Closed Q Altered N/' <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned ® OTR Q 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 4P Other C J,n <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> `�• -A HAULING AND-MANI FEST R EQU I REM ENTS- -_---- <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I 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 O 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 ® In Compliance - No Violations <br /> Q Q Other: § – <br /> Comments <br /> S Com, <br /> Inspection Form Included: Q <br /> Comments Included: ® — U �GU' 21U—*hg�� <br /> �7B s esRep's Sig ature Phone Number Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect: X i,% N E XjA_4P <br /> I Lj#I if 1213 620811 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />