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Waste Tire Su, -.%y & Inspection Report Inspection Report Number ■ <br /> State of California <br /> B 181(New 04104) <br /> Il - 1144037 <br /> California Int grat d Waste Management Board Survey Form - Page 1 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � �, � � - ® � Inspection Type (Fill one) <br /> Site Suffix: O Routine O Re-inspection 0 Referral 0 Observation <br /> Localw \, If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: �.L.y) J(> i�� �(s +C - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit O Other <br /> Business or Facility Name (� ( Inspected By Inspector <br /> Am-Cr cc� 'S <br /> Physical Address <br /> 3-709 E. 1A7om mer-- �_cti✓)e - -- - - -- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM ��^►--II O AM <br /> `,\ ' z PM V S PM <br /> -- -- -- - - - -- J 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 /> of Active ® Passenger *Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler ® Indoor , <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - <br /> V ; A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 1 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 0 Referred!CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 1 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> 7 <br /> Inspection Form Included: <br /> Comments Included: ® t� 31s <br /> — <br /> usiness ep Signature Phon Number s ignature Phone NumberINSTRUCTIONS ON BACK �Correct q Incorrect 1� �/ ,�, p 111- 1262081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />