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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> IBI State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 11 - 1143541 <br /> California Integrated Waste Management Board <br /> PartA- Survey_- -__-- _ _ _ .. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: ` J l "1 [ 41 Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: SG.� Jd��l�l^ CDu�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name S�'� Inspected B Inspector <br /> C�fA ra` VG,` jl��L.. G' � tl2f .�1,8�5 P Y p <br /> q �^, <br /> Physical Address Re-n [c.,46 <br /> -1� c, - U, <br /> 3SD Inspection Date -7 / / l 0 <br /> Time In Time Out <br /> Business Rep Title AM 1 O AM <br /> a PM l O 411111 PM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O fhClosed Q Altere� N/A N/A <br /> GPS Latitude N Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Other Tj U'k e -qi r <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> i <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 Datem / 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 4 � Al t r 1 ��1� <br /> _ —M -W -ems_l�c� _t 1�— <br /> t , <br /> Inspection Form Included: Q <br /> Comments Included: U <br /> �I Business Rep— pec is Signat <br /> 's Signature Phone Number Insure hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X CX A MIPILIE1 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />