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Waste Tire Su. vey & Inspection Repo _ Inspection Report Number <br /> ==o;= State o <br /> f California I 1 - 1143637 <br /> CIWMB181(New04/04) Survey Form - Page 1 <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 /> -7 Site Suffix: ! () l O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � ' ✓� Jt�c��c/l� �C)c�t�L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (ria-r� s Gt✓�-f-trmS 'lm .. <br /> Physical Address <br /> 62 <br /> Inspection Date / f <br /> r1Cn'/�ce� � '33_7 Time In Time Out <br /> Business Rep// Title 0 AM 0 AM <br /> PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> !f <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d <br /> ®Active 18 Passenger a Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business 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 /> 0 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 /> j V !--A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <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 (Required for NOV or EXT) <br /> 14 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 /> i <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 /> Inspection Form Included: Q f <br /> Comments Included: / �- - -- _ ✓(.. T.w.S�S - -_ <br /> Business Reps Signature Phone Number p ct s ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct.-:* Incorrect: t �J } i 62081 <br /> c _l <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ® ■ <br />