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:::::. :::, fir:. . ::.:._•:- �.,., - <br /> Waste Tire Sup Bey & Inspection Report <br /> Inspection Report Number <br /> Stateof California ii - 1144014 <br /> CIWMB181(New 04104) Survey Form - Page <br /> California Integrated Waste Management Board BLUE ORBLACK INK PEN <br /> Part A- Survey <br /> - <br /> - - <br /> Business Profile Inspection Details <br /> j ,Q Inspection Type (Fill one) <br /> Site Suffix: � Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �)CLA SCuqrvn� (61LA k-t - - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address I � <br /> 1 � �0 �)6 <br /> (� (� Inspection Date <br /> cst't�c -1O� "'" ` �, Time In Time Out <br /> Business Rep Title ® AM AM <br /> C� <br /> Q PM 1 O PM <br /> ----- ------- --------- - <br /> --.- - -- — - - ----- - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger ® Generator ® Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR O End-Use Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ - -_ <br /> V A IHAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q OPRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NO or EXT) <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 14 CCR§18460.2-Manifest System Requirements for Logs for 3ears <br /> for Registered Waste Tire Haulers <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Tri <br /> Q O Q Referred!CIWMB Enforcement <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ' O - <br /> Q 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 /> - <br /> Inspection Form Included: 0J <br /> Comments Included: - ---- <br /> Businegnature Phone Number In pe or's ture Phone Number- <br /> -, <br /> umber <br /> - - - - -- - -- _ <br /> _ - - � 62081 <br /> INSTRUCTIONS ON ACK Correct:+♦ Incorrect: ! 1 ' ! I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ■ <br />