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- -- ---------- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California S 1140592 <br /> CIWMB 181(N 04104) <br /> te urvey Form - Page 1 <br /> California Integrated Waste Management Board mess Profile BLUE OR BLACK INK PEN <br /> A- Survey <br /> I Inspection-n Details <br /> TPID- <br /> 01 'Inspection Type (Fill one) <br /> Site Suffix: �,de Routine 0 Re-inspection 0 Referral 0 Observation <br /> L5 If Referral,choose referral type(Fill one) <br /> I <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> =, <br /> Identifier:e r: <br /> Business or Facility Name mmt) - Inspected By Inspector <br /> Cjkjk(N0YJ\ 'IT)C_ <br /> Physical Addresi <br /> 0 <br /> C X5% Inspection Date <br /> Time In #AM Time Out QBusiness Rep Title : 0 ) I : 0 AM <br /> 3 0 b <br /> C71 0 PM PM <br /> Role Storage Type <br /> Operational Status Tire Type Business o e <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> le 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered N/A A)/A <br /> GPS Latitude NA 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck I <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> siness Type (Fill all that apply) <br /> lNew Tire Dealer 0 Auto Repair CCTrucking Fleet Q Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 4j Other 0 tA-T.1511 �16(4 <br /> 1A. --- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! A 1 HAULING ND MANIFEST REQUIREMENTS 1 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§ <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 00 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 � <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators is in compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> A V <br /> If CA 41 <br /> Inspection Form Included: 01 <br /> Comments Included: W <br /> 1 Business Re ignature Phone Number Inspect,�Iignat re one Number <br /> X 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />