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............ .-s.Jr1 ....... <br /> . <br /> CJs s <br /> -J, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State 'f California Survey Form - Page 1 Il 1143488 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> BusJness Profile Inspection Details <br /> 'Inspection Type (Fill one) <br /> ) <br /> TPID- t _ -inspection 0 Referral <br /> Site Suffix: 0 0 I Routine 0 Re 0 Observation <br /> If Referral,choose referral type(Fill one) <br /> Local 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: <br /> Business i®rFaciIiV Warne Inspected By Inspector <br /> Physical Address 39 <br /> (-A q5aD3 Inspection Date 7 -Z- <br /> Time In Time Out <br /> Business Rep Title #AM r? AM <br /> QPM 0 PM <br /> - —_ tiI7Status Tire Type Business Role pe <br /> Storage Type A -- Operational F�I all that <br /> (Fill one only) (Fill all that apply) (Fill <br /> 'I at apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) a--XActive 0 Passenger 0 Generator 0 Outdoor <br /> O 40 Closed 0 Altered 0 Hauler 0 Indoor eelA <br /> GPS Latitude 0 0 inactive 0 Truck 0 End-use 0 container <br /> Longitude 0 Planned OTR <br /> Business Type (Fill all that apply) <br /> 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 4) Other (14 Y1 0 <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 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> & <br /> 0 PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> 0 1 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> � <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance No Violations 0 <br /> 010 Other: § <br /> Comments <br /> C <br /> Inspection Form Included: Qi 9 ^t/y 2� <br /> Comments Included: IVB I u-siness Rep's ignature Phone Number gnature,,os Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* 'moi $JP <br /> ■ X A <br /> Pink C <br /> White Copy:CIWMB Yellow Copy:operator y:LE <br />