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® Waste Tire Sui - Jy & Inspection Report inspection Report Number <br /> 'SE3. <br /> State of California I 1 - 1140844 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _-_ _ - BLUE OR BLACK INK PEN <br /> !Business Profile j Inspection Details <br /> - - -- -- — <br /> TPID- 3 2 _ ! Inspection Type (Fill one) <br /> Site Suffix: lG > 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SYW yV 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 74VA", <br /> Business or Facility Name Inspected By Inspector <br /> r_CJtJG 1in_Lt' <br /> Physical Address 3 - /7i �1IGlf-f '�i`Ct�1 <br /> 214 <br /> O5��� Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> nA 0 PM d is PM <br /> - <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 /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® 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 /> ---------- <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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste fire 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 i <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <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 /> i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Incl0i E ) '7 <br /> Comments Included: J !�f __�/ W-' <br /> Business Rep sigature Phone Number Inspector's Signature - Phone Number_ j <br /> -- - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect t�� E X A p I 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C obw <br /> © ■ <br />