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Waste Tire SL. ,,ey & Inspection Repoi . Inspection Report Number ■ <br /> State of California 11 - 1143654 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part-A- Survey- ----BLUE OR BLACK IN PEN <br /> --- --- ---- <br /> Business Profile Inspection Details <br /> TPID- ; Inspection Type (Fill-in <br /> Site Suffix: 0 l Routine 0Re-inspection Q Referral Q <br /> Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ` � ��(� `J 1� 6A_/q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 39 Physical Address lfy)Xj �l�ry�b-)l <br /> 1,-I b0s- S, itc,v+- C-,f � U\ . <br /> Inspection Date <br /> L�&A-\r"f-D{} 6A y'� Time In Time Out <br /> Business Rep Title O AM (� O AM <br /> �Q J I 0 ® PM V / © ®PM <br /> GlCl6' `t/t l 1 Ct VYL� �fC'✓Iet�i lG'�_ 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 /> - - - -- c ®Active - - ® Passenger- ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ' Q Inactive Q Truck � <br /> Longitude - Q End-Use Q Container <br /> Q Planned ® 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j 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 /> 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 <br /> M / 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 /> 0 O - - -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years i <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 /> Cow n -(4(r <br /> Inspection Form Included: Q <br /> Comments Included: ® - / - e6rfsBusiness Rep's Signature Phone Number In naturePhone Number <br /> - --- -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect I V] t { A Jft�4 E Y 2 3 <br /> ■ <br /> ■ -- - - --- — --- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop A <br />