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`Foca Waste Tire SL . .:y & Inspection Repor�, inspection Report Number ■ <br /> X11 State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1143617 <br /> California Integrated Waste Management Board <br /> Part A.SurveyBLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffix: m 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: Say �bGl��`n ` O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> WO <br /> Inspected By l Inspector <br /> �'t S t\ W O &r 3 I <br /> Physical Address q C� ) <br /> ,A0U'-t L(7�(S (4 - - J WIIIYYY <br /> �(Jt Inspection Date / 0 / <br /> Loa e CA <br /> Time In Time Out <br /> Business Rep 1 l Title O AM O AM <br /> u1 S t. v e4 t T S v CS� (1WI1� - o S PM 3 O 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 0 Passenger ®Generator Q Outdoor <br /> 0 ® Closed Q Altered <br /> G� Latitude O Hauler O Indoor <br /> 0 O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS l <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> Q 0 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 / I]] / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 0 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 <br /> O O ® In Compliance - No Violations <br /> Other: § <br /> Comments �' 1 n r �S ,(. n WqS t <br /> l , <br /> Q U t7�4kiclas Odic ,��G�' C,mCe.0 dl <br /> o <br /> 1 <br /> action Form Included: Q IAN <br /> Comments Included: `Business <br /> Rs "Signature <br /> i nature au I� 7Phon1e'Number - §npe��'sSlg, — - \-A�on�e 0Nu' <br /> mlb/e <br /> r <br /> _ <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X k MrPILIEII 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ,=-t ® ■ <br />