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Waste Tire SL.. vey & Inspection Repoi _ Inspection Report Number ■ <br /> State <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> I 1 - 1140724 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> /'� G Inspection Type (Fill one) <br /> Ste Suffix: ' V t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: SaA ��CX�C U� G L• Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> c� 0 s A <br /> Physical Address <br /> 338 s, <br /> Inspection Date 1 C) <br /> aC'� CA Time In Time Out <br /> Business Rep Title J �! i 0 AM 0 AM <br /> PM PM <br /> f`l, ► l��'i �C`t,C�Ci� �t'1'�VI.Mc�( r�C> -- -- -- ----- - <br /> ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -- ------ o - 1�: Q Active Q Passenger- {o Generator 0-Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR 1 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 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 1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I 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 Q Other: § <br /> Comments <br /> Inspection Form Included: Q! 2 a G ,/*cr <br /> 8 <br /> Comments Included: ® �L-�%'3v���"" _ U = -`-�6-7�- <br /> si s Rep's Signa a Phone Number ISi n ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect ; � \/I 1 ?C A 144i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :LE ® ■ <br />