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Waste Tire Survey & Inspection Report Inspection Report Number <br /> off® State California and Survey Form Page 1 11 - 1140706 <br /> CIWMBB 181(New 04104) <br /> California Integrated Waste Management Bo <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -7 _ r Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / �� If Referral,choose referral type(Fill one) <br /> Identifier: ��12 </!�<<�%Lc-ill Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I� Inspected By Inspector � <br /> Physical Address / ( © / S;�,a <br /> Inspection Date O Q <br /> Time In Time Out <br /> Business Rep Title t') <br /> AM 10 AM <br /> O PM v 0 PM <br /> �GL�LGIIt'.-o'er ��14�e�-C7�i�xc� �'G'/FG-C <br /> -- --- - - - -- -- ---- --- - Operational St usat 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 /> ®Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive � 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 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 HAULING AND MANIFEST REQUIREMENTS <br /> Qi0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 - (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q O - - - <br /> 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 f' tG, j��i C E s^� dxy tree-+✓ VeLt Vete ./✓ L� GtL71�r�.,` <br /> Q�l �- t� c'� �,sGc.t � l,•�C�'-��-'N �t� ��j',7-G'�z-��-�. <br /> �Q <br /> Inspection Form Included: 0, <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature -Phone-Number --i <br /> - - - - -- - -- _ -- -- - —. �' 62081 <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect X /! E A� (- I � <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Cop .L <br />