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® Waste Tire AMy & Inspection Rep"inspection Report Number ■ <br /> State of California I 1 - 1143641 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: l ` 1 l • Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: -�CaqA� c�l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> --- - -- - — <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address39 A hyz�L <br /> -7670 cj . <br /> Inspection Date / 0 <br /> C O <br /> r (./ Time In Time Out <br /> Business Re(��p l Title J O AM ( 0 AM <br /> t 0 0 ®PM GPM <br /> -- - -- -- - - - - - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 60 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i&Active ® Passenger Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O 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 Q Agriculture Q Shredder ® Others <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LENFORCEMENT STATUS ] <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> I Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O O 1 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 O 114 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 1 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q ! Q Other: § <br /> Comments <br /> pvYl C, <br /> �1 r -fiz oylx�­S �� eey� <br /> Inspection Form Included: Q �} q <br /> Comments Included: O WWI, <br /> Bu ass Rep's Signature"- Phone Number Iris a or's Ig ture _Phone Number <br /> -- -- - I A AF - <br /> INSTRUCTIONS ON BACK Correct: Incorrect I <br /> la111213162081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br /> ® ■ <br />