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ispection Report Number <br /> Waste Tire Sur y & Inspection ReportState <br /> Wig <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1140658 <br /> CIWMB 181(New 04104) ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 3 02 © ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c", Thi , ;� c 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name` �� Inspected By Inspector <br /> Physical Address 3 <br /> 2 y E, W cASKAJ-* S . <br /> Inspection Date / O <br /> L.�,cl; LP gszyo <br /> Time In Time Out <br /> Business Rep Title ® AMO AM <br /> i <br /> . 3 2 O PM i 0 -5 ® PM <br /> - - <br /> - Operational Status's Tire Type � Business Role Storage Type <br /> ( <br /> Tire Count (Whole/PTE) Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GP� Latitude 0 Hauler 0 Indoor - -- - <br /> O 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 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 /> VIA HAULING AND MANIFEST REQUIREMENTS <br /> to - ---- <br /> 0 0 it PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 /> I <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 1 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments Q(��� . <br /> - 1 W��. '-ng_- 'Ins L -i cN-,,., - - - C3 <br /> i <br /> Inspection Form Included: 0 •y 1 <br /> Comments Included: ® - <br /> Business Rep's Sign Phone Number nspe�lgnatu Phone Number. <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:X 1ErX E 1 2 3l <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy A <br />