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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California I 1 - 1127931 <br /> CIWMBB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> _ BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I S9 q _�2 O l • Routine Q Re-inspection Q Referral Q Observation <br /> Local ` /� If Referral,choose referral type(Fill one) <br /> Identifier: �j(jk J i/��(1, `CJC A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> �'�` Vi�ress�ea <br /> c� _ 1GPhysical t � � <br /> Inspection Date O <br /> t CA q_15�?vo Time In Time Out l <br /> Business Rep Title O AM r O AM <br /> ' 0 P ClOPM <br /> ��YY1111J`G.t��C'� Jt. �t�t�� tt�Cciti�f ribl'� ---- <br /> i Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � <br /> O Active ® Passenger ® Generator Q Outdoor ^ <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — O Planned Q OTR O 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 O 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 10 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 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 O Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ - <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O Q Other: § <br /> Comments <br /> Insp ection Form Included: <br /> Comments Included: O'i �fit-VGA-Y�73_ <br /> Business Rep's Signature Phone Number Ipsp c is Si n ur Phone Number <br /> -- — - - - -Ph-one <br /> - 081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect. i I t ' 2131 <br /> White <br /> ■ Copy: ■ <br /> CIWMB Yellow Copy:Operator Pink py <br />