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=vJ Waste Tire Su ,y & Inspection Reportonspection Report Number <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 114116 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- E - Inspection Type (Fill one) <br /> LASite Suffix: � t 5 L01 .'S 1 L� 16 ( 1 0 Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Std VL (�(.(G L � 1 O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> +or Facility Name Inspected By Inspector <br /> 11 1E% -� <br /> . ... <br /> Physical AddressCck - <br /> Scree; Inspection Date <br /> City State ZIP ;ode Time In Time Out <br /> Business Rep Title ' L' O AM I O AM <br /> L 0 P / lc QPM <br /> t 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 /> r Q Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder Q 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 /> ---- - — -- O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 ' 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance No Violations <br /> O Other: <br /> Comments Lu}l 1 1)194)11 1'7Z1 21, C C Y1 e C7 1 42 I'S CC& <br /> T� <br /> G -- <br /> _� C—L t��� 7/Z-) 1. <br /> Inspection Form Included: 0 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> __ _� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X A 1A P I ,E l 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />