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Waste Tire Survey& Inspection Report Inspection Report Number ■ <br /> «� State California I 1 - 1143684 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA-Survey__—_-. _ - . _ --,_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l u I e� Inspection Type (Fill one) <br /> Site Suffix: ' 1 -L { Q Routine Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C 1�� <br /> X11 '_1 CIJUATk' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> � <br /> d �d a <br /> Business or Facility Name Inspected By Inspector <br /> S(4 w 01 <br /> Physical Address <br /> [000 <br /> T G l A CA 1,3`)7 Inspection Date / � O <br /> JTime In Time Out <br /> Businessep 1 Title ( J0 AM 0 AM <br /> MC l 9�I� Tfw'vaQf�'[ M4k. 1 l —1 U O PM I is PM <br /> --- -------------- -- - - -- -- -- - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � f <br /> 10 Active Q Passenger • Generator Is Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler • Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use I Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <br /> ----------- -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> 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 /> f <br /> Comments Pft �oUt <br /> � ,S 1(t.�.._ _�_I,,^ �„�� (4 2 V � lel00 1'y <br /> 1 <br /> concv n k {Qnvf r� <br /> Inspection Form Included: QII +�, �� <br /> Comments Included: Q; - - - <br /> Business R ignature Phone Number Insp'eV11'r" <br /> s Signature one Number <br /> - - -_ <br /> r MIP-Mel. 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect 1. <br /> ■ -- --_.. —----- ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />