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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California I 1 - 1143504 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> art A- Survey_ -_ <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� I ' � _ © I Inspection Type (Fill one) <br /> � � <br /> Site Suffix: "� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: SCk J Det,u!I T WU 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name t Inspected By Inspector <br /> Physical ldr6s � I n CO O <br /> (PA Hot Man <br /> S4 <br /> 1,,'- C^I, <br /> Inspection Date 0 I <br /> Time In Time Out <br /> Business Rep Title 5 O AM O AM <br /> 0 PM PM <br /> —� --- =-- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> 0 Active 0 Passenger S Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 A Ort <br /> - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I. ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 DateM / 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 DCT) <br /> 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments (� _� �t __ W�.�¢..��'L�- tl llc,��� L,.. ��7 ►�J(AWA 6f�� �1J1� /AfJ�� . Q.TI�eJ <br /> Sex- C_(ac`(� nA;5_- psr -% <br /> I <br /> Inspection Form Included: O1 — <br /> Comments Included: <br /> Oi slness Rep's Signature Phone Number Insp&j �turyr' Phone Number <br /> - - - <br /> � 62081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect: ; , ? ) 11 ! 213 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink CO-- A �� ■ <br />