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Inspection Report Number <br /> Waste Tire Sur sy & Inspection Report <br /> ME.-i <br /> L 1, State of Survey Form - Page 1 1 1 0 7 9 0 5 <br /> CIWMB 181(New 04/04) � <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: / Q 3 S A ,Z � � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _5111 �� � � / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ,/ =«tit`s- l/�, _ / xf <br /> Physical Address ,,f�zeoa <br /> Inspection Date �, J <br /> Ad9S'e7/J <br /> Time In Time Out <br /> Business Rep Title `,� ,� ®AM s S S AM <br /> v p( 0 PM O PM <br /> 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 /> ®Active ® Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> � New Tire Dealer 4j Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ­Aj HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle / m / m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �1yy+¢_ �'�s �j' G�Ci Cle'cc�✓ .�t .>-�� `{!�Y° b �( <br /> ell <br /> IV V <br /> Inspection Form �nc <br /> ncluded: Q <br /> Comments luded: Q. <br /> u Ine R s Signature Phone Number Inspector's Signature Phone Number <br /> - ---— � � . 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( E ,?CAMP t_ f; 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />