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Waste Tire Asey & Inspection Rept Inspection Report Number <br /> State B California I 1 - 1127478 <br /> CIWMB 181(New Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> — -- ---- ---- --- <br /> Business Profile Inspection Details <br /> TPID- V__ �� � � � _ � Inspection Type (Fill one) <br /> Site Suffix: 3 1 * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,/1 ` n� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Uv t/ Inspected By Inspector <br /> Physical Address <br /> qQ�j Inspection Date � Z O <br /> 5�c Time In Time Out <br /> Business Rep Title O AM O AM <br /> D J 11111111 PM d PM <br /> ���lGltN1 <<�► Mhct � <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 /> p� 4&Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 End-Use Container <br /> 0 Planned 0 OTR . <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> V 1 A HAULING AND MANIFEST REQUIREMENTS 0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O <br /> 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Le In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments S <br /> - <br /> ��c� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 ` -- �09 ��—,D�' <br /> Business Rep's Signature Phone Number In _c 's ig ture Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X µ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :LA <br />