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- Waste Tire Su..r & inspection Report spection Report Number <br /> A <br /> State of California <br /> CIWMB 181(New nage Survey-Form - Page 1 r i 5 - 1 0 9 1 4 <br /> California Integrated Waste Management Board � <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details . <br /> TPID- � t.' � , Inspection Type (Fill one). <br /> Site Suffix: K { 7 D . <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP Q CIWMB- Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> ,J P y Inspector <br /> Ph slcal Address - <br /> I�Jex PTA, <br /> 77 Ve <br /> Street I <br /> Inspection Date n �f � 1 Cj / • /'� � �i <br /> Clty State -ZIP Code�, Time.ln Time Out <br /> Business RepTitle Q AM <br /> i m ' m0PM � ' 0 P <br /> (o,:::�10 JA, <br /> l r� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I� / n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q)Active Q Passenger i Q Generator Q Outdoor <br /> O O Closed 0 Altered <br /> GPS' Latitude Q Hauler Q Indoor <br /> Q <br /> O �OPla�nned <br /> Inactive O Truck <br /> ^ <br /> 'Longitude - 0OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ---- - - .. <br /> Q New Tire Dealer Q Auto Repair OM Trucking Fleet Q Government Q Retreader f Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber . <br /> Q Service Station. 0 Hauler O Agriculture Q Shredder Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS' <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years - --- <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O i 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � In Compliance - No Violations <br /> O O Other: § - —-- -- <br /> Comments dGt lYL! C �f��'7f L� r•'. f �t�'. �1�1 G:�L/ G1 ` ( ( I` __ / �. <br /> j - <br />,` Inspection Form Included: 0 // y <br /> Comments Included. Q; , :. - .1i .._ - ------lo� <br /> -- --- <br /> Business Rep's Signature Phone Number Inspectof signature- -- Phone Number J' <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 'w I ;, `',�P .2 62081 <br /> • - - - ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA • <br />