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Inspection Report Number <br /> Waste Tire �ey & Inspection Rep ■ <br /> State of California <br /> CIWMB181(New04/04) SurveForm ' Pa e 1 11 - 1086936 <br /> y <br /> California Integrated Waste Management Board ! � —- - - <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> `BusinessProfile Inspection Details -- - <br /> TPID- r Inspection Type (Fill one) <br />} Site Suffix: P I y I I �- , -� A[Aj ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local CZ r� .} If Referral,choose referral type(Fill one) <br /> Identifier: ��! 1. F ` ,C ` ,' y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - r- <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street p 'Ell x, <br /> Inspection Dater` <br /> � � <br /> --- Time In Time Out <br /> City State 7lfi Code _._ _ ----. <br /> Business Rep Title " O AM j� O AM <br /> ` -�- . f Q PM `' Q PM <br /> IIS 1�" III _ <br /> Operational Status ,;0 yjie Business Role S age Type <br /> (Fill one only) (Fik all that apply) (Fill all that apply) (Fill all that apply) <br /> i <br /> w 0 Active 0. Passenger ( Generator 0 Outdoor <br /> _ 0 0 Closed O;Altered 1 ' <br /> PS Latitude <br /> T p 0 Hauler 0 Indoor <br /> G <br /> 0 Inactive 0`Truck <br /> T7 iD <br /> Longitude - ° , F 0 Planned Q OTR 0 End-Use 0 Container <br /> I 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 (D Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 0 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 I CIWMB Enforcement <br /> 0 0 Iii 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 In Compliance - No Violations <br /> 0 0 Other: § - - <br /> Comments <br /> r_ <br /> Inspection Form Included 0 <br /> �• '" -- - <br /> Comments Included <br /> Business Reps s Signature Phone Number InspectorSignature Phone Number <br /> - - - - __ _ - 62081 <br /> — T <br /> d <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: y ; A MIP! L g 9` <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />