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= 13_ Waste Tire Su. ay & Inspection Report nspection Report Number <br /> �(Iit1- State of CaliforniaCOMB 181( ew 04104) <br /> T Q R R q <br /> California Integrated Waste Management Board Survey Form - Page 1 + 1 O 8 8 O`� v <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 0 D Lr ( - O 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: SCtV� G�(/11'� (C'L'n( C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V �� <br /> Inspected By Inspector <br /> Physical Address <br /> -7 Mctwk <br /> Inspection Date 0 �l 0 3 l O <br /> mctrt�c�. Q5 36 <br /> Time In Time Out <br /> Bu ss Rep Title { IAM 1 � 5 <br /> �-1 l � � 0 PM 0 AM <br /> ® PM <br /> S ©� 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 /> f ' 0 Active 0 Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> G P$ Latitude Q Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer • Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer 0 Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 7Oi AND MANIFEST REQUIREMENTS O Notice Of Violation xtenslon <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline' <br /> Q <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date `` <br /> 0 0 14 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 /> -- - <br /> Q • 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- - --- -=--- <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB.Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ' <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> n Compha o: ._ _. �..10 1 ._ <br /> Q Other: § IML <br /> Q <br /> Comments ` ) )L1 e, i`W),DPC tilsn OU—ne— cm _, kks <br /> TI �� <br /> A_rcs.._ �C�YI_ce�n'. i�i e_l�l CCR R 6459.3 -off av <br /> ears tactI'I u crL:s 6r Elecfrr-nic <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - - — �--� <br /> Business Rep's Signature Phone Number Inspecis ig ture Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPI62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />