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Waste Tire Survey & Inspection Repor` Inspection Report Number <br /> State of California Il - 1140595 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> P-1 A- Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> '*ID- � � � � I � /_ _ � � Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� ' If Referral,choose referral type(Fill one) <br /> Identifier: G o 61Adun Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> TrU GXw'I 1� <br /> Physa Address - r o b <br /> — <br /> � 0 <br /> ^ ���� Inspection Date <br /> 7 Time In 1 Time Out <br /> Business Rep Title O AM O AM <br /> Zp�,f &Ak' w%1 blJl).ner � � PM � ' � � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �J Q Active Q Passenger Q Generator Q Outdoor <br /> PS - L-atitude - D • Closed Q Altered <br /> IJA NI <br /> A <br /> GNIA Q Hauler QIndoor <br /> Longitude 0 Inactive Q Truck <br /> Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair ® 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 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 <br /> Notice Of Violation Q Extension <br /> Q Q Q <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 li 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 /> 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 t <br /> \\ C15� 1 o_1�_OLu�n <br /> ntspection Form Included: Q (V/ � Wao� k,Comments Included.� — '"Business Rep's Signature Phone Number Inspec r s Signature ne Number <br /> - -- --- <br /> - - -X 1 `f 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. <br /> FE X ! L , <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> White copy:ulvvivio --- <br />