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Waste Tire Su I . <br /> ay & Inspection Repor` Inspection Report Number ■ <br /> IIA State of California I 1 - 1144030 <br /> CIWMB 181(New 04104) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> r -«A- Survey -. --- -- - ----- <br /> ness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' J� 3 O L2 01 <br /> • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad EssCA ��fZJrtSOmL.CJ( . <br /> g_ Inspection Date L 9 <br /> ( CLL�� `� Time In Time Out L <br /> Business Rep Title O PM PM <br /> — ------ --- -- -- ---- Operational Status Tire Type Business RoleStor <br /> age Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f <br /> Q Active Q Passenger 41 Generator Q Outdoor <br /> 0 * Closed I Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive (ID Truck <br /> Longitude Q OTR End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> ',Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> u 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 f�1 ar► Vont <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA !HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> �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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 EX7) <br /> Q Q 114 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 <br /> in Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ction <br /> Included: <br /> 1,2 <br /> 11"peComments Included: Q� / <br /> 401 Bu ne Rep's Signature Phone Number I e ors I lure Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON ACK <br /> Corr( <br /> Incorrect: % �/! � ' � E L; 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />