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Waste Tire Survey& Inspection Report Inspection Report Number <br /> � <br /> State B181(Nrnla Survey Form - Page 1 1 9 - 0 0 6 3 9 <br /> CMIMB 181(New 04104) Y g <br /> California Integrated Waste Management Board "�' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile nCCn �r Inspection Details <br /> TPID- IV-40 t� Inspection Type (Fill�5 OCT —5 p� ,3 2 <br /> Site Suffix: Ilf I Q Routine Q Re-inspection Q Re erral 19 Observation <br /> Local If Referral,choose refer a�F.� J UI tn� ��RR C 0 UN T y <br /> Identifier: twi+.-� �-�T � Q CHP Q CIWM�t"�� Laintn A&FFQtI fional Visit Q Other <br /> q i <br /> Business or Facility Name''— I <br /> Inspected By Inspector <br /> Physical <br /> sisal Address <br /> J a ss <br /> Streer Inspection Date , 2 / M114 <br /> city — D State ZIP Code Time In Time Out <br /> Business Rep Title 0 Am 0 AM <br /> PMO 0 PM <br /> _ 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 /> 1 ® Active ® Passenger •Generator ®Outdoor <br /> i t i O Q Closed Q Altered <br /> GPS Latitude I ,I I -j J — Q Hauler Q Indoor <br /> ___ 1 1li r _ I _ IC Q Inactive ®Truck <br /> Longitude i i I , I I Q Planned Q OTR Q End-Use Q Container <br /> III <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 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 Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q ® 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for fYOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 10 1 Other § I n <br /> Comments l LIS ( Q1A5 jr <br /> �s,�-fes -h_"►� vA/s 1�eept►� 1'- '�S�s <br /> —q>� u�,c� rs�,� .�l - –w--lam•-- �—r Gr- !~-�- wasrf���, e�fi" <br /> r rVc- <br /> Inspection Form Included: Q r _ <br /> Comments Included: - <br /> Business Rep's Signature Phone Number In ector's Signature Phone Number <br /> �-�/ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:�& �J E X A Mt P L1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />