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Waste Tire Sur . _y & Inspection Report nspection Report Number <br /> Gi7I State of California <br /> Survey Form - Page 1 I - 1 7 4 1 0 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f 3 y J Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y,� C <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -J <br /> 1 / Inspected By Inspector <br /> Physical Address / 3 `7 <br /> Inspection Date 2- <br /> Time <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> • PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 130 <br /> The Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 10 Active <br /> Q Passenger 9 ® Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 Q Agriculture Q Shredder ®Other 4*qt <br /> 1.1 -- -- _ y '' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q- -- — - -- - -- -- Q Notice Of Violation Q Extension <br /> 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 <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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> --- ------ -------------- ----- - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 i ® p s <br /> Q Q Other: § In Com Rance - No Violation <br /> Comments <br /> lytic z r 4 <br /> Ake <br /> Inspection Form Included: Q <br /> i <br /> Comments Included: Q <br /> Businas ep' Signat hone mber Inspector's gni ure Phone Number <br /> - - . <br /> INSTRUCTIONS ON K i Correct Incorrect:' p � 62081 <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA <br />