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O <br /> Waste Tire Sufty & Inspection Report aspection Report Number <br /> 16 <br /> State of California — <br /> CIWMB 181(New 04104) Survey Form - Page 1 11 1141222 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L - Inspection Type (Fill one) <br /> Site <br /> Site Suffix: f ' Q Routine Q Re-inspection Q Referral 0 Observation <br /> Local c If Referral,choose referral type(Fill one) <br /> Identifier: \.r; �CACJIJ VA r(A., � Q CHP 0 CIWMB Complaint Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> LA2 <br /> scree: p <br /> Ins ection Date <br /> r;r,.. state ZIP G>de Time In Time Out <br /> Rep Title <br /> Business Re -•- -. _ .._._ O <br /> AM AM <br /> �) V O PM O PM <br /> 1 - ---T_a L Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (fill all that apply) (Fill all that apply) (Fill all;that apply) <br /> Tire Count(�IVht)le/PTE) <br /> O Active Q Passenger: Q Generator Q Outdoor <br /> O O Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder O 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 0 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 1 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 /> Q O 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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 <br /> Q In Compliance - No Violations <br /> Q O Other: <br /> Comments <br /> ' t <br /> - Cyy —pec(3 <br /> Inspection Form Included: Q. ' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 11�, E �X,A_M + 62081� <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA © ■ <br />