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Waste Tire Su y & Inspection Report nspection Report Number <br /> State California Survey Form - Page 1 1 - 1140601 <br /> CIWMBB 181(New 04/04) y g <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: 'S- (421 t - 0 C 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S44,- Vv 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> -- <br /> Business or Facility Name Inspected By Inspector <br /> 1lv�r ooc(�j �Ct�ut r - l <br /> Physical Address ✓✓ 3 <br /> &44"_ /-fC1C.r�i <br /> Inspection Date 1 O l d <br /> Time In Time Out <br /> Business Rep Title 0 AM 70 AM <br /> PM Ll S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � � II <br /> ®Active ® Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer a Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 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 /> 1 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 /> 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 <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 1 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> -- - �rru.�'1n.e1 �N C�C�'7'c� '�v --lZ,�:C !�er�r..� C,�„��1 •f�. <br /> ��L? ✓Yu - GvrEt c {�{j A <br /> Inspection Form Included: 01 { l <br /> Comments Included: <br /> - - , `�yJZll w g`04, j <br /> B /Rep's <br /> Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I EiXI A M _ EIXI 12131 <br /> 62081 <br /> White Copy CIWMB Yellow Copy Operator Pink Cop :LE <br />