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Waste Tire ,A&y & Inspection Repoms Inspection Report Number <br /> State of California 1 �+ a <br /> CIWMB181(New04104) - Survey Form - Page 1Zjf! <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 1 Inspection Type (Fill one) <br /> Site Suffix: l ,1 �, fl ' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f` If Referral,choose referral type(Fill one) <br /> Identifier: { i;/�; r ; ',� ( ;_,.•� } 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v Inspected By � Inspector <br /> Physical Address r.- .; L—dilL_! _ 1t r _!;�, /VY ; r , <br /> Street <br /> T t Inspection Date li 1� / / L (�• <br /> -� I _ <br /> Cita State ZiF Code Time In Time Out <br /> Business Rep Title OAM 1 0 AM <br /> O PM O PM <br /> ZU1 f_1L <br /> C ) Operational <br /> one only) <br /> Status (Fill ire Type apply)f Business Role Storage Type <br /> Tire Count Whole/PTE !. (Fill all that apply) (Fill all that apply) <br /> ., , <br /> f V I Q) Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> Longitude — 1 - - ! 0 0 0 0 End-Use 0 Container <br /> 9 0 Planned 0 OTR <br /> Inactive ruck <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 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 /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 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 / 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 /> 40 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 l0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § _ _.. <br /> Comments ; <br /> ZA <br /> i <br /> Inspection Form Included: 0'---- - <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> " •`. w' ` _ 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X ' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />