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Waste Tire Sui .ay & Inspection Report inspection Report Number ■ <br /> ==s State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 — 1143478 <br /> California Integrated Waste Management Board <br /> _ -_ BLUE OR BLACK INK PEN <br /> part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- i /Y� Inspection Type (Fill one) <br /> Site Suffix: 1 $ q a v I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r' 1 If Referral,choose referral type(Fill one) <br /> Identifier: ���J () L�'l f'1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> ao aA Sec\j <br /> Physical Address 3 I V J ��nIWv <br /> WAO S . <br /> L1A �533b Inspection Date ! l S ] O <br /> CA nP CA Time In Time Out <br /> Business Rep Title 0 AM D AMI <br /> I o J QPM I O (6 PM <br /> - --- —_ —-- - — — - ---- ( Y) apply) ( apply) Storage Type <br /> Operational Status Tire Type Business Role <br /> Fill one only) (Fill all that a I Fill all that a I (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active Q Passenger 9 Generator 0 Outdoor <br /> — - - - <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use i 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 Q <br /> Q Service Station Q Hauler Or Agriculture Q Shredder O Other (npb�lt�j f� \241 r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V A 1 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 m / M / m <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 /> Q O <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/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 I Q Other: § 11 f L 11 A <br /> Comments Q04i u., V34,STe. 11 Af [)<0 ."11"" C).&P Q.& ot1Ar1,,i<' �kA,�_ <br /> ^ 1 Ain <br /> 1 -- - -- - -- -- -- - <br /> No vio�akX'OIII S CIC u[C-a A concern . <br /> Inspection Form Included: Q <br /> comments included: �ij <br /> BVusinsSignature Phone Number Insp or's Signature Phone Number J <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. '^ N! (E SCI A MJ P (_J CJ I j 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />