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Waste Tire ection Report Numbert <br /> ® State of California I 1 - 1088467 <br /> eai�a Survey Form - Page 1 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-_Survey -Inspection Details — BLUE OR BLACK INK PEN <br /> Business Profile , -- - -7 <br /> TPID- k= Inspection Type (Fill one) <br /> Site Suffix: _ liaRoutine Q Re-inspection Q Referral Q Observation <br /> Local Ru If Referral,choose referral type(Fill one) <br /> Identifier: 5a JU L'� }1 U 1�l n ' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address -� �n <br /> Strut <br /> tate �yip Codi I Inspection Date <br /> Time In Time Out <br /> City _Business Rep Title j j AM �t:} } AM <br /> *G <br /> ' ` t 0 P J 0PM <br /> Jr <br /> Operational Status Tire Type <br /> t.�__.._�_w��^l'' p � yp � Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)i <br /> Active Q Passenger 1, (1) Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS - Q Hauler Q Indoor <br /> O <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Q Agriculture Q Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> QIO - - - <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: <br /> ' Comments <br /> Lf AIj <br /> 3 <br /> Inspection Form included Q t1 a' <br /> Comments Included, 01 � <br /> Business Rep's Signature Phone Number Inspector's Sign ture Phone Number <br /> - _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A� X JAI'P E t. 2 3 <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy'Lt F+;'1,� <br /> - i <br />