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is Waste Tire SdOey & Inspection Repors Inspection Report Number <br /> •��� State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 I1 - 1127486 <br /> California Integrated Waste Management Board <br /> Part A—Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O Inspection Type (Fill one) <br /> Site Suffix: D 0 ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local n �� If Referral,choose referral type(Fill one) <br /> Identifier: w J ��l/ �(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N,0rmA,n q _ ( 1 <br /> Physical Address 3 � EC r, <br /> ano W6f) <br /> Inspection Date I / O <br /> �Sao Inspection 3 q <br /> Time In Time Out <br /> Business Rep Title0 AM Q AM <br /> ® 1 � 1 -O QPM V 1 � PM <br /> 94-- --- - -- -- --- - - --- --- — -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l ® Active 0 Passenger o Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that aPPIY) ------------_---- ------ -- ---- - - —-- <br /> Q New Tire Dealer i 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- ---- ..-- --- -- — <br /> V I A�HAULING AND-MANIFEST REQUIREMENTS <br /> 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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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/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 /> Dry 1 > <br /> to <br /> 'F&6�4 J-1 of 65 �i rs,<, a4 aj�o D )1��a�j T�f C5 <br /> ilnspection Form Included: Qj <br /> - --_ (_� <br /> Comments Included: Q - - - - — --- <br /> B _m Rep's Signatu _ ho Number Inspe is Signature _ Phone Number <br /> - - -- <br /> INSTRUCTIONS ON BACK Corr •e ncorrect: % Ij N- L4 X A, M P 1 t � 62081 <br /> White Copy:V <br /> Yellow Copy:Operator Pink Copy:LEA <br />