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Waste Tire Su.. y & Inspection Report nspection Report Number <br /> State California I 1 1140718 <br /> CIWMB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business_Profile jlnspection Details <br /> TPID- Ui - nspection Type (Fill one) <br /> Site Suffix: 4 b O I 0 f ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: &Itn 1 00- tYN 10 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 11 Inspected By Inspector <br /> Physical Address 3 - / 0 ,Q,� 'r•�`G�' <br /> C_E 7� <br /> Inspection Date 3 ` / f 0 <br /> Time In Time Out <br /> Business Rep Title e,r ✓ AM O AM <br /> ` f/ � � U QPM � -;2- PM <br /> --- f 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 ® Generator * Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive (®Truck <br /> Longitude - 0 Planned 0 OTR 0 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> , V <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> .............._.____.______—___—_ ____.--___..- -_ _____..__ - 0 Notice Of Violation 0 Extension <br /> 0 1 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 /> 0 0 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 Other: § <br /> Comments �--� <br /> Rcpt-nit, 1 nC prx Ai cml­' Crime f �j I2A*4'1 <br /> (.� f to o ---- <br /> ,Inspection Form Included: 0 / 1 <br /> Comments Included: - o k ��g` <br /> Business Rep's Signature_ Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X lie X A 1 2D <br /> White Copy CIWMB Yellow Copy:Operator Pink opy: <br />