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L ' Waste Tire S,.-. .ey & Inspection Repo. _ Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 - 112 7 9 2 6 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_- BLUE_ OR BLACK INK PEN <br /> 'Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l/ (� CA l V 1 + Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: lc11� (,l ,J Nv Lo(„A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l 14-r?-t r.�, <br /> Inspection Date 1 � � ' � � 1 <br /> Time In Time Out <br /> Business Rep Title &AM AM' <br /> O S 0P Q D 0P <br /> Ti,vic,TvY to - <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 /> 6 Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler a Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 40 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 I 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 / M / m <br /> Q Q 14 CCR§1B459.1 -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 /> Q Q 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 <br /> � n A,� <br /> Inspection Form Included: QI <br /> Comments Included: 0 - - --- - - ` h 7J� - <br /> Business Reps Signature Phone Number In ctdr' ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect I, 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: © ■ <br />