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Waste Tire Su. y & Inspection Report4spection Report Number ■ <br /> State of Californi- <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 11278731 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S _ Inspection Type (Fill one) <br /> © 2 <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S,!An 1 I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busir Facility Name ness oJam`" <br /> Inspected By Inspector <br /> a�ww <br /> 4v_►(20-rc�_ pr-0 h CLAA� 3 l / <br /> Physical Address - U <br /> ���n1Gb foc�ih <br /> .2 S-3 -7 & . ,poS�, RCA . - - <br /> Inspection Date <br /> S �-O�� C A ci 'S2vs- <br /> Time In Time Out <br /> Business Rep Title q ` 3 0 AM 0 j S 0 AM <br /> I � 0 ® PM ! QPM <br /> 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 /> ' ' ® Active Q Passenger 9 Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive ® Truck <br /> LongitudeQ Planned I- Q 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 0D 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 Q 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 <br /> PRC§42953-Contracts with ler Registration <br /> Waste Tire Haulers.of Tires <br /> lers. O Notice Of Violation Q Extension <br /> O O <br /> PRC 42951 -Waste Tire Hauler Re Istration and Trans <br /> Q Q § 9 Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date O / m / m <br /> Q O 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 /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities -_ <br /> O tQ 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: 01 ' <br /> Comments Included: ® -- - - - - - -- - <br /> Business Rep's Signature h <br /> er nspector's Signa ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK !� Correct: IncoE X A' E � � � <br /> White Copy:CIWMB Yeor Pink Co y:L <br />