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■ Waste Tire Sup Bey & Inspection Report Inspection Report Number ■ <br /> =;« State of California Survey Form - Page 1 <br /> � CIWMB 181(New 04104) y g I 1 - 1140757 <br /> California Integrated Waste Management Board <br /> Part A- Survey -_ BLUE OR BLACK INK PEN <br /> — - <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: I ® (0 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local -3 If Referral,choose referral type(Fill one) , <br /> Identifier: �Gt,f) u I n (DA <br /> (�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> nl � � A3n I 1 C Physi QSSS -Ti1� Cl,�l - {� (j <br /> Inspection Date I 2' 8 I <br /> Time In Time OutJ <br /> Business Rep {� Title O AM O AM <br /> A\ —� o PM -- - 3-� is PM <br /> Dwsks' <br /> - - --- -- - — Operational Status Tire Type Business Role S <br /> Tire Count (Whole/PTE) torage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 <br /> ®Active 40 Passenger ® Generator ® Outdoor <br /> -- - - O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive ®Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> I_ <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> PInspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Part B- 1 - <br /> HAULING AND MANIFEST REQUIREMENTS <br /> ,Q Q PR - Q Notice Of Violation Q Extension <br /> C§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 r <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O _ - <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years � <br /> Q Q 114 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers I Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 14 CCR§18462-ManiI* In Compliance - No Violations <br /> Q Q Other: § <br /> Commentsk_4C e� n 1A n Olbr <br /> COCA 1"Coke 0u-I-\� <br /> No - <br /> Inspection Form Included: QI <br /> Comments Included: 101 <br /> Busine Flep's Si ature Phone Number Insp�Wr.Siq,ature Phone Number <br /> -- _ � I � <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: i �;+ X A M1 <br /> _ _ V2 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />