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011211 <br /> Waste Tire Suil - 4 & Inspection Report inspection Report Number <br /> State of California <br /> CIWMB181iNew04104) Survey Form - Page 1 I 1 - 1140690 <br /> California Integrated Waste Management Board J `�,J' <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 3 3 3 Is Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 'SaYN T0Ck$-V-'n CpL.VVtiI"� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ��11 i �d Inspected By Inspector <br /> k� 14C.{�vv�-tt d�, .t <br /> Physical Address U — r �� I <br /> Inspection Date / © / 0 <br /> At Gl Z o C <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> k'' // ((�� ' c) Q ® PM I. 7 e PM <br /> r_" f�Xy� t/1 1 vt t vVX__tV\_j - — <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 /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> I J Latitude -- - - -. --- -- — Indoor <br /> O 0 Inactive 0 Truck i e muter 0 <br /> Longitude — 0 Planned 0 OTR 10 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 le Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation (� Extension <br /> _._. -- ---..._- _ .............._ .._..._... - _._ ._ _.. __-.._ ..___�_ <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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 ® In Compliance - No Violations <br /> 0 1 0 1 Other: § L <br /> Comments 7a ( �C <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> ® � ` )LIt"g-0162 <br /> Business Rep Sign Phone Number 'Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X . E--X- din 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y: <br />