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® Waste Tire Sup ,rey & Inspection Report 'Inspection Report Number <br /> -Iri State of California I 1 - 112 7 8 9 7 <br /> CIWMB181(New04104) 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- r� Inspection Type (Fill one) <br /> Site Suffix: ` 3 0 Q V - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:- }/� , �h LC ti 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> ���� � 00ale, - 1 0 1 Jn� <br /> Physical Address t� ( �� / �ti <br /> r �7'� �/�j Inspection Date 1 1 LJ 1 1 <br /> b " - CA Time In Timle OutL <br /> Business Rep Title <br /> Q AM AM <br /> ' O ®PM DPM <br /> �;,�1 P�t;�-�— Svc. -- -- - ---- -— -- - <br /> _ — - - -- Operational Status Tire Type Business Role Storage Type <br /> S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � � Ci31 <br /> ®Active Q Passenger It Generator Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> � Q Inactive ®Truck <br /> Longitude - O Planned OTR Q End Use Q Container <br /> Business Type (Fill all that apply) _ ___ __ <br /> Q New Tire Dealer Q Auto Repair ® 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 O Agriculture Q Shredder Other �n �n°C�t 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> �/ A HAULING AND MANIFEST REQUIREMENTS Q 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 /> O O 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 /> O (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 O Referred/CIWMB Enforcement <br /> OO 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ___ <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> LSV - <br /> Inspection Form Included: <br /> Comments Included: ® - - - <br /> us ness Rep's ignature Phone Number s ct is gn t Phone Number <br /> - --- -- -- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V C l�4 L a 2 9 <br /> ■ White --- - -- ® • <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy: E <br />