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Waste Tire Ak :ey & Inspection Rep Inspection RepJlt Number ■ <br /> ■ '[i[S.it State of California <br /> T' CIWMB 181(New 04104) Survey Form - Page 1 Il — <br /> 1127462 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Soto 40aqu In u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name Inspected By Inspector <br /> Ce�c-0 k n�eJt�Ck�i T� Ser v y 1 <br /> Physical Address <br /> 1'C Inspection Date <br /> S �C At -b c" JYL^� J Time In Time Out 1 <br /> Business Rep Title O AM O AM <br /> C * PM PM <br /> V (� <br /> f 0 W (7wou <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 /> ' *Active (0 Passenger ® Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 4 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 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 /> Q Notice Of Violation Q Extension <br /> 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 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 EXTJ <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 /> . 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments50zk l C)n S w <br /> N,�D\lk)&1) 0 5 (du (A M US <br /> wqA lo-y(ro Wilk CS <br /> Inspection Form Included: Q V Q n <br /> Comments Included- Q 4f <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: \/ ( � i! A P f 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: <br /> ® ■ <br />