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= Waste Tire Su, . .:y & Inspection Report Inspection Report Number 1, <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1143516 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (� - V Inspection Type (Fill one) - - - <br /> Site Suffix: IS Routine Q Re-inspection Q Referral Q Observation <br /> Localy �"L)'VA <br /> If Referral,choose referral type(Fill one) <br /> Identifier: Sa \ ��Vl, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address c3 9 ' ryuo Arcc bu/ <br /> IAC 1 63 ,rt <br /> Inspection Date O d <br /> (l V� � Time In v Time Out [ V <br /> Business/Rep Title l AM q �� 1 0 AM <br /> �L1,�, O PM 1 ( ✓ t - ® 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 /> f V ® Active ® Passenger 4W Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> Comments <br /> - - - ------- - rnel3 <br /> Inspection Form Included: Q <br /> Comments Included: ® �� <br /> Businp's Signature Phone Number Ins or" i nat re <br /> ess R Phone Number <br /> - - - - <br /> INSTRUCTIONS ON BACK Correct:* incorrect: E p M 1 3 62081 <br /> White <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copk.jV <br /> ■ <br />