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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1140569 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> A.-Survey-_- -- <br /> ness Profile Inspection Details <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix: r 5 5 3 O 1 Routine Q Re-inspection Q Referral Q Observation <br /> Localr' 1 If Referral,choose referral type(Fill one) <br /> Identifier: �(�� J Q[�j I 'n (0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �(�v�u. 1 a C,a.r-LU. 3 q - I d l <br /> Physical A rens Es��y <br /> to �q3 S . kaiser � • - — ----- --- — <br /> Inspection Date <br /> C A l ' I <br /> S�acJ�2k�n !j'1� Tc5ais Time In Time Out <br /> Business Rep Title O AM I 0 AM <br /> I 'l 5 ® PMl S PM <br /> - - - - <br /> -- -- - - -- -- - --- --- Operational Status Tire Type I Business Role Storage Type <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , IllnJ <br /> Q Active * Passenger i � Generator Outdoor <br /> -- - — 0 10 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Longitude <br /> D PlannedQ Inactive Q Truck <br /> g• Q I OTR Q End-Use Q Container <br /> - - -- - I ------ -- - - - <br /> - siness Type (Fill all that apply) <br /> 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 A HAULING AND MANIFEST REQUIREMENTS 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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 (Required for NOV or EXT) <br /> CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 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 /> - - — ----- o I v djn5OV oI[c_-c+S__Asph Ce Ln. <br /> Inspection Form Included. Q - <br /> Comments Included: --- -_ <br /> 41-,50 70 - <br /> Business Rep's Signatur Phone Number Inspec is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK correct_ incorrect: 1113 <br /> Al �/ � � A � �! �- � � i � <br /> ; � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> ■ <br />