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Waste Tire Sup .jy & Inspection Report Inspection Report Number ■ <br /> State of California 11 - 1143957 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey__- - BLUE OR BLACK INK PEN <br /> Business Profile - - - Inspection Details — <br /> TPID- , � � � 1 1 � � � � I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: Say JDt�,C�M1(� C,�t+tC1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C"A-%K Dck.y n j , ,10(-. <br /> Physical Address <br /> t t7 Inspection Date <br /> �S33o <br /> P Time In Time Out <br /> Business Rep Title ` o AM ` '® AM <br /> 1 , v QPM ` 0P <br /> Lo no\c &'i'11) "V,s �1a d C- - - - - - - - - - <br /> - --- - - --- ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ll (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active ® Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 41 Indoor <br /> p Q Inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> -0 New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q 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 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q O - _ - <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 11 121�jf X11 �J1�4� U-+ <br /> - T c 1�L�j�cr 1� f1 6"t'01 <br /> t\v-- �CQAOLt)iCL� <br /> 'Inspection Form Included: Q, - <br /> Comments Included:10�Usi <br /> s Signature Phone Number Inspec is Signature _ Phone Number- <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �( A X , ,�,h p L� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />