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® Waste Tire SJfey & Inspection Repofflolnspection Report Number <br /> i6 State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 I l - 1143481 <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: i Ll 5 3 l i Routine Q Re-inspection Q Referral Q Observation <br /> Local ] If Referral,choose referral type(Fill one) <br /> Identifier: }���, 4 e�� c , 1 lZ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> FE <br /> Physical Address <br /> 39 A l ,^ kynto 13 <br /> CAC _ Inspection Date 7 f <br /> Time In Time Out <br /> Business Rep Title 9y O AM '] O AM <br /> vt 9 PM raC m 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 /> Q Active Q Passenger (lb Generator Or Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rE ORCEMENT STATUS <br /> V AI HAULING AND MANIFEST REQUIREMENTS <br /> d Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Numberfrom CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required far NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 <br /> ® In Compliance - No Violations <br /> Other: § .--_ _--- <br /> Comments ` r <br /> )�twhnel lytsp )2ncmd-2ltw ,Z " l l-�, Ala <br /> . 11 Fa c.r Is 7L4 /z <br /> re,cn,m mP,,,6 Close, <br /> Inspection Form Included: Q <br /> Comments Included: Q — ------ ---- ---- --- — --- — o�© _Y - <br /> _ Business Rep's Signature Phone Number a 00 <br /> _tu _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect rGy l "' 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Co y: ® ■. <br /> l <br />