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Waste Tire & Inspection Rep` 7spection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I1 - 1141341 <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) j <br /> Site Suffix: I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �t�y If Referral,choose referral type(Fill one) <br /> Identifier: �r 1 -,kAebo� (&V l I �/ O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Address <br /> a l i 6 maw <br /> Inspection Date /+'1 <br /> E_-_sc'f-" ' ` CCAI- 75S Time In l Time Out✓✓ <br /> Business Rep <br /> ll Title I ®AM i � [ GQ AM <br /> O PM PM <br /> i � U IlGt / 6 S' u� <br /> - - -- I Operational Status Tire Type I Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)1150 0 'I <br /> Active ® Passenger • Generator ® Outdoor <br /> 0 Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> Q O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> o New Tire Dealer O Auto Repair Q Trucking Fleet O Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS ®,Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> - 2 In Compliance - No Violations <br /> O O Other: § W `f 35y -S S t`n -- <br /> Comments <br /> 41 <br /> Inspection Form Included: 2 j / Y� y� <br /> Comments Included: --� - �a� !Busin s p Signatu Phone Number Insfe Phone Number <br /> 11 1 62081 <br /> INSTRUCTIONS ON BAC Cor ct: Incorrect: I �X k ►, F 111213 <br /> White'op} ;,11Pli�; `^rc w '�oerator Pink Copy:LEA <br />