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nspection Report Number <br /> Waste Tire Sui . y & Inspection Report State California <br /> NZ SurVe FormCIWMBB 181(New 04104) y Page g 1 11 - 1127487 <br /> ment Board <br /> California Integrated Waste Manage <br /> Sart A- Survey _-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5Inspection Type (Fill one) <br /> Site Suffix: l I I Routine Q Re-inspection Q Referral Q Observation <br /> Local III If Referral,choose referral type(Fill one) <br /> Identifier: �� CJ(,yt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �►1c�-►��� Ire / ,, <br /> Physical Address 3 _ l Vp� 1 �`6- l4z�rn,buIG <br /> aDSp Cs ' q5 3 30 �. <br /> Inspection Date 1 1 Ll O <br /> 1__c, n 6 l I 1 <br /> Time In Time Out <br /> Business Rep Title 1 0 AM I 0 AM <br /> n - 1 Q ®PM 1 � — ® PM - <br /> --- �4- -- � -— --— 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 /> f 0 Active Q Passenger is Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> i <br /> 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 E.Y7) <br /> Q Q 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 Q Other: § <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: Q -- / Cjr �� -- <br /> mess Rep's Signature Phone Number In cto ignature — Phone Number ] <br /> INSTRUCTIONS ON BACK Correct: Incorrect: `"� �/lf]�k P y 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py:L <br />