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40 <br /> ilWaste Tire SA" Inspection Reporoction Report NurraberState of California 1 - 1144034 <br /> CIWMB 181(New 04/04) Survey Form _ page 1 <br /> CalifomialntegratedWasteManagementBoard BLUE OR BLACK INK PEN <br /> - urvey <br /> ness Profile Inspection Details <br /> TPID- ? / 1 ` Inspection Type (Fill one) <br /> Site Suffix: 1 Q Zj Ct ) a ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 4fOCXL Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> gsat <br /> Time In Time Out <br /> Business Rep Title / 0 s� <br /> tr rl OPM © 0 P <br /> 4fkn 6v, 6(v 6mOperational 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 Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler S Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q End-Use — Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ®Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> �V A 'HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> 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 Q 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 /> ispection Form Included: Q <br /> Comments Included: 0 <br /> — <br /> Busines ep's ignatu Phone <br /> Nuumbeer I pct Signature _ Phone Number <br /> — . `\!� Ct ' 62081 <br /> B jrorrect: Incorrect: — <br /> INSTRUCTIONS ®N t ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:operator Pink Copy:LEA <br />