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S <br /> = Waste Tire Orvey & Inspection Rep Inspection Report Number ■ <br /> • ,➢➢ State of CaliforniaCIWMB 181(New 041 <br /> w04104Tl 1 1140969 <br /> Calif Integrated Wastement8oard Survey Form - Page 1 1 <br /> Pert A-Survey-_- -- - BLUE OR BLACK INK PEN <br /> iness Profile Inspection Dstalls <br /> ..,ID- Inspection Type (Fill one) <br /> Site Suffix: 5 8 © ( ® Routine O Re-inspection O Referral O Observation <br /> Local [['� If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name fff Inspected By Inspector <br /> Physical Address 1 O 416,s- AyeK <br /> _ Inspection Date 0 (' <br /> Time In Time Out <br /> Business Rep Title I <br /> ' <br /> L I t f ® AM 0 AM <br /> 'L Q PM PM <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 /> ➢ O Active it Passenger 40 Generator 0)Outdoor <br /> 0 ® Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 O Inactive 0 Truck <br /> Longitude - O Planned ® OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> LoServicenfC.�rl�'r'UL Station O Hauler O Agriculture O Shredder ® Other 4cA 4c'-r-{it6�t:'-J fcc-4ctA <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS I (O Notice Of Violation O 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 <br /> 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 EX7) <br /> O O -- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years I <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 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 In Compliance - No Violations <br /> O O Other: § - <br /> Comments <br /> m -- ---- <br /> lection Form Included: O <br /> Comments Included:® ----- A Bus Phone Number is i nature —_ Phone Number <br /> r 62081 <br /> INSTRUCTIONS ON BACK correct:* Incorrect: > <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />