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=R Waste dire Suy.& Inspection Repo Inspection Report Number .. <br /> ■ c.c <br /> z&6°= State of California <br /> .iias. <br /> CIWMB 181(New 04/04) Survey Form - P age12 - •�- 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q <br />} I - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ 4 i If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> III <br /> Inspected By Inspector <br /> Physical Address J V ( Itrtbll •,k�t��, <br /> I <br /> Street <br /> Inspection Date <br /> ori <br /> City State ZIP Code <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 7 mm0PM EE QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q 1 f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �I 0 Active Q Passenger tD Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m , Q Hauler Q' Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use e`Container <br /> ✓r. <br /> Business Type (Fill all that apply) <br /> I (3 New Tire Dealer Q AutoRepairQ Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I . <br /> �E0UsedTire Dealer. Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V_° A HAULING AND MANIFEST REQUIREMENTS <br /> - - --- — <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Manifesng Requirements ' Date m /. m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from Cl MB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire T Ip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 (3 14 CCR§ 18462.—Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments V V1111�#e +iep ` Off Is,)fe. 21j <br /> f ✓iri! Utf f10(.ly'_� <br /> �levVed �hcavii,1 > t �4�or rz Cir �+tiitil�*cli1cle <br /> A , W I V4 '�r9c WPrff< ?0�{slyII� 1''r Ur{ �tCt r�P11� <br /> Inspection Form Included: <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: -71112 <br /> 62os1 <br /> • 4(�jEjXj,A'MjP[LjEj <br /> �■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © S <br />