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Waste Tire Su 3y & Inspection Repor, Inspection Report Number <br /> 0e` State of California . <br /> CIWMB181 <br /> Waste <br /> Survey Form - Page 1 I 1 - 108806 9 <br /> California Integrated Waste Management board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 1 V - I OT11 • Routine Q Re-inspection Q Referral Q Observation <br /> Local \^ If Referral,choose referral type(Fill one) <br /> Identifier: Y\ �oc�t,b��V CQU� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected B <br /> P Y Inspector <br /> 3 1. l 101 ( t1 1 foY�So �tr�'rl bolG <br /> Ph'sical dress �—_.._ — \{ <br /> Inspection Date <br /> Street <br /> �S —�i- Cp � ao61 I L <br /> City S ata ZIP Cod.. Time In _ Time Out _ <br /> Business Rep Title �- I I I�O AM I 1 - j I Q AM <br /> f� I <br /> I—L_�I !_ I I® PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) y'� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f V ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q_Dismantler Q Tire Derived Fuel <br /> ® 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 I 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 111ENRORGEMENT STATUS <br /> A <br /> V HAULING AND MANIFSTEREQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <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 /> 7Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <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 FX7) <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 I C-IWMB 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 8Qhn <br /> ` o c <br /> AcLL�i���2�2s <br /> Inspection Form Included: Q F I y R <br /> Comments Included: Q - <br /> siness p' t ture one Number In cto s i nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co reet: Incorrect: X A MIPILIEI 111213 <br /> White Copy. IW Yellow Copy Operator Pink Copy:LEA <br />