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00210040289 <br /> Waste Tire Su .;y & Inspection Repor Inspection Report NumberBB State of California <br /> CIWMB 181(Now.04/04) Survey Form - Page 1 Il 108806 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- Q -T Inspection Type (Fill one) <br /> Loi <br /> Site Suffix: I I U I Q I $ 16 I l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: u—'- ' G..Oy1�1"`7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> Physical Address—_r_ / O ` I <br /> Street <br /> Inspection Date <br /> L—Lhi�(f' l <br /> City tS ate Z/P Code Time In Time Out <br /> Business Rep Title O AM I �f Q AM <br /> ® PM j02 1 ' �6 ;0 ®PM <br /> e�. _C� ;,Xv� t/�. _ _. !J_ T�rt✓1� ✓� = Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) .(Fill all that'apply) (Fill all that apply) (Fill A that apply) <br /> Tire Count (Whole/PTE), <br /> f ®Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GP$ Q Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ® 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EX7) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest'System Requirements for Registered Waste Tire.Haulers Q Refereed I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> Q Q1 Other: § _ <br /> Comments <br /> WYL-s <br /> Inspection Form Included: Qcz� app o i -u .�675 <br /> Comments Included: Q - ! —�� 1� I <br /> Business'Rep's Signature Phone Number Inspector's ignatu e,'q Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C7,reIncorrect: E X A F 1 Z 3 <br /> White C Yellow Copy:Operator Pink Copy.LEA <br />