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Waste Tire Survey & Inspection Report Inspection Report Number <br /> -;TIS T 1 <br /> State B California survey <br /> �e Form - Page 1 1 1 1140565 <br /> CIWMB 181(New nage) J y ry <br /> California Integrated Waste Management Board y <br /> part A- Survey_ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> ID- Inspection Type (Fill one) <br /> �Site Suffix: J it Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(�(� � �n (uun 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> (NO Inspected By Inspector <br /> Physical Add e <br /> ���. ecee,� DG�sy ��c _ <br /> ss <br /> ah -.5 0 p (ZA, ---- --- . 1 <br /> M � r\ �� ����'V` Inspection Date 1 I / 0 <br /> Time In Time Out <br /> Business Rep Title � � C OAMJ � PM Q AM o 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 5 t 3 l( <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active 0 Passenger S Generator Outdoor <br /> — - - - - - -- O ®Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler .Agriculture 0 Shredder 0 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 /> 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. I Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 1:11 / 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 /> 0 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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § _ <br /> �,� r ! 1 t `� 1 L <br /> Comments Tl�,u!- � S �Tl 11 �pQ5(Y1PFl <br /> o�i0-lc�-v-.tng� 1 cTU.gL�c�- <br /> ection Form Included: m <br /> Comments Included: * Business Ct11 eA J o 3 <br /> Rep's Signature Inp �r17QV <br /> Phone NumberSignature \ hone Number <br /> — ------ <br /> INSTRUCTIONS ON BACK Correct Incorrect: J E M A 4 I El I 11 i3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />