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Waste TileSufty & Inspection I or inspection Report Number <br /> State of California a r <br /> �® CIWMB 181(New 04104) <br /> 1 0 0 5 3 <br /> Sur,vey Form - Page 1 - <br /> California Integrated Waste Management Board - _- <br /> Part A- Survey `, BLUE OR BLACK INK PEN <br /> - -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 1 ., fy (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - } If Referral,choose referral type(Fill one) <br /> Identifier: !<l Ulm C;.� .ti i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> -1,A <br /> Physical Address <br /> Street ( l <br /> Inspection Date <br /> City Slate ZIP Code Time In Time Out <br /> Business Rep Title � � AM Q AM <br /> QPM • �� QPM <br /> t Y10 Ur7IF OVI <br /> �; Operational Status Tire'fype ' Business Role Storage Type `I <br /> (Fill one only) (Fill all that apply)! (Fill all that apply) (Fill all that apply)] <br /> 0 Active 0 Passenger 0 Generator 0'Outdoor <br /> Latitude Q 48 Closed 0 Altered <br /> GPS m • ��'_ �� 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 0 Planned 0 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ; A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 0 In Compliance - No Violations <br /> 0 0 1 Other: § - -- <br /> Comments j7� 11 �/' /< <br /> ~✓''_, ! 7, K��` <br /> f.JE J^ ND Qf`.k ----- <br /> c.1 wl r'Yy V1(l _f-� l} (0-< C r' It D <br /> j 4- <br /> -—-------------------- <br /> Inspection Form Included: 0 ' <br /> „I <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> s 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �° I_ L t2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />