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_ �e & Inspection Reoo Inspection Report Number <br /> „ Waste Tire <br /> State of California <br /> CIWMB 181(New 04104)ment Board Survey Form - Page 1 Il - 1143759 <br /> California Integrated Waste Manage <br /> PartA- Survey —_ BLUE OR BLACK INK PEN <br /> 'Business Profile Inspection Details <br /> TPID- 1 n I Inspection Type (Fill one) <br /> O <br /> Site Suffix: ` l fj Routine Q Re-inspection 0 Referral Q Observation <br /> Local � n}� If Referral,choose referral type(Fill one) <br /> Identifier: n J 0"1W <br /> n 1 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C ' �i �nk <br /> Physical Addre &r) VS � <br /> ass w C-C oj) Q,(A . VVV <br /> AInspection Date 2 <br /> Time In J Time Out <br /> Business Rep V Title ,1 AM AM <br /> (� c <br /> ' b y PM Q J O Q PM <br /> �CASSO- - - - --J - --- --- - - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1- ®Active (8 Passenger ®Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> D O Inactive • Truck <br /> Longitude - O Planned • OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> I* Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q 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 I A )HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 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 S In Compliance - No Violations <br /> O 1 O Other: § <br /> Comments {�0_-A ,n= ion pl!"FONA 0r\`� A 3 (/�q�C ildlr� �V�C��Q&I A21 DA WAS nOt�� <br /> VA 1D <br /> �c7Cc C t`� V--,)C, NPr��W2 �� I`��5�-�(Jt�rS (AS 1 <br /> ,Ins ection Form Included: <br /> Comments Included: Q - - -- -- --- - -V <br /> ("� <br /> -- <br /> Business Rep's Signature Phone Number knspe�r�ignatur <br /> hone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect i 1, l X A P I Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co L ® ■ <br />