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FLFF <br /> Waste Tire Su. ,y & Inspection Report inspection ReportNumber <br /> Lid State of California <br /> CIWM6181e ) Survey Form - Page 1 Il - 1140907 <br /> California Integrated WaststManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 11 Business Profile 1 Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 0 Q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> i�n _ Gtrt.. tri: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 17 1 o ��;?YlGli1IP.C� IJC��✓�'1`t�t�, <br /> 3% 15 % /Vc'w'zo 7, <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title OAM O AM <br /> 0 '3 . 3 a 0 PM 0 ® � PM <br /> r3,� 1-1F3 <br /> 'tlf ooKkec-pc,W -- - - - - - - ®- <br /> - - --- - - Operational Status Tire Type Business Role I Storage Type <br /> Tire Count (Whole/PTE) .2- 0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f 0 Active 0 Passenger I* Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive I ® 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 /> - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> r V A HAULING AND MANIFEST REQUIREMENTS <br /> ---- - 0 Notice Of Violation 0 Extension <br /> 0 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 /> § Y q <br /> 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> a rx�rerhr � - vn _ 1�s c,/4Ec � <br /> Inspection Form Included: 0 X / 6 1 <br /> Comments Included: — - <br /> Business Reps Signature Phone Number Inspect"'.s Signature - _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK 1 Correct: Incorrect: X X A P L - � 112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />