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8, Waste Tire Sup jey & Inspection Report. Inspection Report Number � <br /> Stateof BCalifornia SurVe Form - Page 1 <br /> � CIWMB 181(New 04104) y g I i - 1143484 <br /> California Integrated Waste Management Board <br /> -- _ - BLUE OR BLACK INK PEN <br /> Part A--Survey <br /> _ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( 3 C) ® Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name ((( Inspected By Inspector <br /> �S fvc��1 A-0 in <br /> 1R Ct.ZC - <br /> Physrcal Address �i7 j <br /> Inspection Date -7 Z <br /> ( ) <br /> —" q �Lt),- Time In Time Out <br /> Business Rep Title ) 0 AM 0 AM <br /> rr} J <br /> �'f I 0 PM , V G/ ® PM <br /> CLC` t / S� t ► (G vl�l' ✓ - --- - <br /> ---- ---UOperational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � � <br /> 0 Active Q Passenger Generator ®Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O 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 Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators It In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> cf1_60m11MC'4_/�S_j_1a_ <br /> - U <br /> Inspection Form Included: <br /> Comments Included: - - _ <br /> q6 51' 73 - <br /> Busine ure Phone Number In4pt In t a Phone Number <br /> � X- 62081 <br /> INSTRUCTIONS A K Correct: Incorrect E A MVe, 11 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink tf <br /> ® ■ <br />