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Inspection Report Number <br /> y � Waste Tire arvey & Inspection Rei. t <br /> H-2. <br /> State of California <br /> CIWMB181 <br /> asteMaage Survey Form - Page 1 I 1 - 1141350 <br /> California Integrated Waste Management Board <br /> Part A- Surv_ey _ _ BLUE_OR BLACK INK K_ PEN <br /> Business Profile - Inspection Details - <br /> TPID- ' 9 3 S c -S _ O 1 Inspection Type (Fill one) <br /> Site Suffix: *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �wl l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> hACi ')0 ' ` l ' �I�Lc� <br /> Physical Ad rens .l � © j •�I,�,� {,.� ��I�,�I„ <br /> 55� Inspection Date / 1 Z� f �� <br /> Time In Time Out <br /> Business Rep TitleO AM �] 0 AM <br /> � 0 PM ! 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 /> 1 ® Active Passenger ®Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber J / <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - --- <br /> Y— A HAULINGAND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 !PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / [j] <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i CIWMB Enforcement <br /> 0 0 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 /> 0 0 Other: § <br /> Comments Abvt�� vac �' rfi'D � JS -- <br /> I 1 — f� �] <br /> (Inspection Form Includd: 0, ) q <br /> Comments Included: <br /> usiness Rep's Signature Phone Number s is 'gn ur Phone Number <br /> / _.. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �. �/ {� EX 2 31 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pinko y: <br />