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r Waste Tire Su. -%y & Inspection Repor"Alnspection Report Number <br /> State California I 1 1140722 <br /> CIWMBB 181(New Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: Z / ! '® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Su.✓, `�G�� "� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other i <br /> Business or Facility Name---/ <br /> Ivvnc,- Inspected By Inspector <br /> � �K s <br /> Physical Address <br /> I . , Inspection Date tD 9 / a -q- / i v <br /> 9s33 � <br /> Time In Time Out <br /> Business Rep Title ` ® AM { _ AM <br /> � Q 02 vQPM ! / 0 P <br /> Operational Statusl Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j 3 y i(Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger O Generator ® Outdoor <br /> - I I <br /> Latitude Q Closed Q Altered <br /> GPS I Q Hauler ® 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 /> Retreader Q Dismantler® New Tire Dealer QAutoRepair Q Trucking Fleet vernment 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 <br /> Q Q 14 CCR§ 18459.1 -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 /> - - clin. �► � 'i n-S�c�, c,)"_ o <br /> �ol(cr1.•.t�� 'lv�s vto-1-�c.0 .° <br /> Ins ection Form Included: 0, <br /> i Comments Included: - -- <br /> i Busine s Rep's Signature Phone Number Ihspector's Sig ure Phone Number <br /> -- - - --- - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1 E XIA4 J 1 j 21 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />