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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California 11 - 1143983 <br /> CIWMB 181(New 04104) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey -- -- - - -- - - <br /> ---- - ----- <br /> ness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J 3 l p2 Q ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /— �^ If Referral,choose referral type(Fill one) <br /> Identifier: �Uy" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address b } V C <br /> �A C 7-� Inspection Date 5 <br /> 95z) 1 <br /> -SCCc,�iJ�'1 6 ` o Time In Time Out <br /> Business Rep Title ll ' J 77 Z Q®AM j� O AM <br /> L I O PM r �l ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> v (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 Q Generator Q Outdoor <br /> D 0 Closed Q Altered A/14 //4 <br /> GPS Latitude IVIA Q Hauler Q indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End Use Q Container <br /> Rusiness 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 /> 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 Yrrt(mss ��L\ fta ?0r_15P <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENF6RCEMENT STATUS <br /> V-1 q I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> QQ 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 m / m / <br /> Q 014 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O 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 <br /> Q Referred I 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 Q Other: § <br /> Comments <br /> Inspection Form Included: Q' *sq <br /> Comments Included: ® e —� Number <br /> siness Rep's SIg ture Phone Number ure Phone Number 62081 <br /> INSTRUCTIONS O BACK Correct: Incorrect: XGf■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />