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I A=k <br /> Ffi Waste Tire Survey & Inspection Report Inspection Report Number <br /> State California Il - 1140745 <br /> CIWMB 181(New 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- � I Insp ection Type (Fill one) <br /> Site Suffix: 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �\- ' / If Referral,choose referral type(Fill one) <br /> Identifier: J ut I7 ( f1u�'� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v" <br /> _1 Inspected By Inspector <br /> Physical Address 31 <br /> W"k q l 4 0 L f04 11 ►�.1/\ -- 11.JXC„1 ' -- u J <br /> '�k o c---, VA isia Inspection Date V 2 I D <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> L Q (1 <br /> 49 PM v V PM <br /> - - —----- - — ----— - <br /> Operational Status Tire <br /> ---- ---- -- p Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f1 11 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active S Passenger ®Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude - 1 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> IV A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other § In Compliance - No Violations <br /> DiI <br /> Comments 0 _ort f 1r ' <br /> ` <br /> Fo <br /> Inspection Form Included: 0 � C� tu <br /> `Comments Included: Business Rep's Slgna re Phone Number Inspe or'sSignare v Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X � �/ ; L 62081 <br /> -- - - _ -- <br /> ® White Copy:CIWMB Yellow Copy:Operator Pin Copy <br />' IIIIIIIIII� White Copy:CIWMB renow Lupy.-pciawi - -- <br />