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: Waste Tire fty & Ins ection Re Inspection Report Number <br /> State of California I� ■ <br /> CIWMB 181(New04104) Survey Form - Page 1 I 1 - 1143815 <br /> California Integrated Waste Management Board <br /> Part A-.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Inspection Type (Fill one) <br /> Site Suffix: t(J ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S u J � 1.(1 n Ott 1 — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> 0�.`�S �C uc.� _ <br /> Physical Address 1 � _ to <br /> a3',-7-o C , Lei nc. KA. — <br /> � <br /> %o Inspection Date O 1 / <br /> ��Ul CA l Time In Time Out <br /> Bus ines Rep Title 1 O AM O AM <br /> G. 1 J G� ® PM O m PM <br /> v SwD a rt -- - - - - - - - <br /> --- —— -- - <br /> ___—Operational 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 /> Ll S Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 4ft Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f CIWMB Enforcement <br /> 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators . In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> _ _ _ --- Ccr 11 -- Q lk Lk Wu <br /> A d 0s � Q&S 01 __c0f) <br /> MmVs� n _ - r 4)' �,�� <br /> ,Inspection Form Included: 0 Q <br /> Comments Included: 0 ZD4' �. V,0 -- � <br /> Business Rep's Signature- Phone Numb r Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK rCorrect:10 Incorrect: 7JW / }� , P - 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:LEA <br /> 1\ <br />