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Waste Tire SUS ,,ey & Inspection Report Inspection Report Number ■ <br /> lt�l;l State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1143476 <br /> California Integrated Waste Management Board <br /> Part A_--Survey -- ---- ------.---_ -- --- -._ -- BLUE OR BLACK INK PEN <br /> !Business Profile Inspection Details <br /> i TPID- inspection� � � I - 0 Inspection Type (Fill one) <br /> �Site Suffix: f 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: )(�TQ (��)n ��,��} 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business ��or Facility Name <br /> Inspected By Inspector <br /> �sqCwl Q t 3 <br /> Physical_Address Sc+Nll r 1 - <br /> I o 1 gxn ,;Cato <br /> 1 a Inspection Date I <br /> CScw�o n �,� Is3�.(7 �O <br /> Time In Time Out <br /> Business Rep Title ` 0 AM 0 AM <br /> � ' U V ® PM � l 5 QPM <br /> —- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger 6 Generator • Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned • OTR O End-Use Q Container <br /> Business Type (Fill all that apply) u <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O Agriculture Q Shredder 41 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 /> O O j PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> �14 CCR§18459.1 -Tire Program ID Number from CIWMB i <br /> O Q 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> . _ . - _ .. - <br /> 0 Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators o In Compliance - No Violations <br /> O 0 Other: § <br /> Comments K)44N , ' f, <br /> Inspection Form Included: O, 6g"JIComments Included: BusiSignature lD7�Phone Nui* Insp 's Signure <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: Y :" <br /> " X{E A M p E t 1213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />