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Waste Tire Sur Bey & Inspection Repo Inspection Report NumberState of <br /> ■ <br /> CIWMB 181'(New 04104) Survey Form - Page 1 11 - 1127691 <br /> California Integrated Waste Management Board ! �/ <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile inspection Details - - <br /> TPID- Inspection� Inspection Type (Fill one) <br /> Site Suffix: ` 10 V Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sum J(�(L�l,�;n ��L(I � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> fy`Ii,-�s <br /> Physical Address <br /> 1;a15 Inspection Date l I b <br /> Time In Time Out <br /> Business Rep Title OAM �l O AM <br /> 0 PM O V PM <br /> ---- --- - -- — -Q 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 /> 0 Active Q Passenger ® Generator Outdoor <br /> O Q Closed Altered <br /> GPS Latitude Q Hauler Indoor <br /> t) Q Inactive �Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q 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 /> 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> —o0 <br /> �lo�r � �ucal;kucee, Noy ;c�. <br /> ;Inspection FormIncluded: Q <br /> Comments Included: - - /'`'��'/(p< �dZ©3 - - - <br /> iness Rep' gnatur Phone Number Inspe is Signature Phone Number J <br /> INSTRUCTIONS ON BACK [Correct. Incorrect �f,. s P -` 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />