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Waste Tire "ey & Inspection Reps* Inspection Report Number ■ <br /> ■ 1� State of California <br /> CIwM8181(New 04104) Survey Form - Page 1 Il - 1143669 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE-OR-BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: 1 36 1 l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� (� If Referral,choose referral type(Fill one) <br /> Identifier. ��C X1(1 ��)ck(6 NA �E�l n [(�/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name lJ <br /> Inspected By Inspector <br /> Physlcal`Adaress� �2SU�PcC:Ns �"' N 3 <br /> Inspection Date <br /> '�ttic C A <br /> -'?S-3-7 L l? CJ <br /> Time In Time Out <br /> Business Re Title O AM O AM <br /> O PM O PM <br /> ---- - - — -- ---- - --- 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 9 Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered /I!A <br /> GPS Latitude r4/A Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O End-Use Q Container <br /> Q Planned Q OTR <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 40 Other A A <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> — --- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> l <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> !inspection : <br /> Form Included: O <br /> Comments Included:®II - - - _... - -Aspi - i�!-LI�Lf�-7 <br /> Business Rep's Signature Phone Number e Phone Number--]INSTRUCTIONS ON BACK ICorrect: Incorrect: ( 62081 <br /> � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />