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Waste Tire SuiSy & Inspection Report Jnspection Report Number <br /> State Llai CIWM f 81(New <br /> Survey Form - Page 1 Il - 1140560 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' f © ( - Inspection Type (Fill one) <br /> (t <br /> Site Suffix: P © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local .If Referral,choose referral type(Fill one) <br /> Identifier: 5�1 �Gy,V✓�,, ( gV <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> tBusiness or Facility Name Inspected By Inspector <br /> . C�/0-r ra rrn 5 <br /> �Physical Addl*�ss 3 0 <br /> /00 �'v. �GC.�rJi LO Rd �Gc•'tG /7 <br /> Inspection Date I O 3 / / 0 <br /> Time In Time Out <br /> Business Rep Title O AM <br /> _ <br /> / O AM <br /> 3 0 OPM ®PMarrC " z-c - 1%AxeAevfr7anp :M' r perational StatusTire Type Business Role Storage <br /> (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill allthat apply)y)Tire Count(Whole/PTE) <br /> f - ' 0 0 Active Q Passenger ®Generator Q Outdoor <br /> Latitude O Q Closed Q Altered /V M <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> -- <br /> i Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENF0RCEMENT8'll <br /> A I HAULING AND MANIFEST REQUIREMENTS <br /> V 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / 1 <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 forNOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years ------------ <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers QReferred CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance ''-, No Violations <br /> Q Q Other: § <br /> Comments <br /> —QOUJOLu In t: ,-C� C&I11t f r f 1.� <br /> Inspection Form Included: Q X <br /> fir) �(,-gPo6 z <br /> Comments Included: --- - - - - -- -- — - - -- -- <br /> ®,Business Reps Signature Phone Num spector's Signature Phone Number <br /> - ------ - - - - -- ------ - --- --- - - - <br /> INSTRUCTIONS ON BACK Cgrr+ek #t > � E%X I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pin Copy: <br />