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Waste Tire Su ,y & Inspection Report Inspection Report Number <br /> State of California <br /> , CIWMB 181(New Survey Form - Page 1 I 1 - 1140816 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 // sT Inspection Type (Fill one) <br /> b <br /> Site Suffix: 6 3 3 C7 U - U I ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical A rk ss u S er 3 9 ""/ � <br /> /7Jn4olek (JG9e 7 CC <br /> !O 1 S" icy <br /> li Inspection Date / 2- 3 <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> QPM l -3 S ® PM <br /> NP 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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) Til t <br /> Q New Tire Dealer _0Auto 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 ® Other 2a1 yc ,,Ha Ca,7S.)77 1/, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT_ STATUS— <br /> PRC 42951 Waste Tire Hauler Re istration and Transport of Tires J <br /> V I A 'i HAULING AND MANIFEST REQUIREMENTS <br /> Q Q § g. P Q Notice Of Violation Q Extension <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 <br /> Q Q 114 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 P Lo9s for 3 Years <br /> � <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 <br /> ® In Compliance - No Violations <br /> Q Q Other: § - -- <br /> Comments <br /> Inspection Form Included: Q, <br /> - - ,-- <br /> Comments Included: ® - -- - - <br /> Business Rep's gnature er Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: , i 62081 <br /> - - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />