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Waste Tire Sur , y & Inspection Report ispection Report Number <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140791 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile IInspection Details <br /> TPID- 1 ` _ / Inspection Type (Fill one) <br /> 3 O <br /> Site Suffix: 10 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� • I.,�, If Referral,choose referral type(Fill one) <br /> Identifier: (�' 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !/ Inspected By Inspector <br /> !✓�� C- IC�?Yf f S <br /> Physical Address 3 — l <br /> 3z3 Sr��x-ri cc P 64" <br /> Inspection Date 02 C� <br /> Time In Time Out <br /> Business Rep Title O AMO AM PM <br /> oZ D U ®PM 3 ® <br /> /3�r W�S� amu. �� �. -- - - l <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) i (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> L I _ <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 <br /> --- -- — — -- -------- --- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 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 / 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 /> 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 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 00 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> -/, V <br /> av,go�7'l��ULv/nj !/�/%c r pjGl�la� <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: ® *aturePhone Business Rep's SiNumber Inspector' nature Phone Number <br /> ___.- _ _�_ --. 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: . X A` F 112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copv <br />