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rWaste Tire Su, „ay & Inspection Reporl,. Inspection Report Number <br /> State of California <br /> � <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1143976 <br /> California Integrated Waste Management Board <br /> ^art A- Survey BLUE OR BLACK INK PEN <br /> Isiness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 7_0 © 1 5 I Routine Q Re-inspection Q Referral Q Observation <br /> Local `• If Referral,choose referral type(Fill one) <br /> Identifier: sck.r t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �- + Inspected By Inspector <br /> Physical Address 69 <br /> , L. / r4m6,j Ic <br /> 4l oo s- Cn�rr�c�n A�. --- - <br /> 11 Inspection Date 5 1 1 Q <br /> Lfb I CA R�dZI v ( I <br /> Time In Time Out <br /> Business Rep Title Ilb AM AM <br /> I �y <br /> n � �✓ 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O i Closed Q Altered n/{/} IVIA <br /> GPS Latitude /� Q Hauler Q Indoor <br /> O Q Inactive Q Truck �A <br /> Longitude - Q Planned Q 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 0-Dismantler Q Tire Derived Fuel <br /> J 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 !V / A <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> A I HAULING AND MANIFEST REQUIREMENTS <br /> Q QQ 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 EXT) <br /> i <br /> 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 i`In Compliance - No Violations <br /> Q Q Other: § <br /> Comments lV1 4,V4, <br /> G ,��.; - G' f iUt�5Kvr�ct v�Ia-ac�T- m_mn u <br /> inspection Form Included: � <br /> Q �___ <br /> Comments Included: Q �� Y6� �6�3 - <br /> Business Rep's Signature Phone Number In tors g ure Phone Number <br /> INSTRUCTIONS ON BACK Cor rect:0 Incorrect: t X A MJPI�JEJ it I 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />