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Waste Tire Survey & Inspection RepTrle Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1143778 <br /> California Integrated Waste Management Board <br /> -_ BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details - <br /> TPID- c Inspection Type (Fill one) <br /> Site Suffix: J Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 54 n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M v alVv_y e�us��f � n� , snc- 3 q - � 0 1 � CSc�� <br /> PhysicalAddress ++ C_0 <br /> )S-Job S. ��I\gin' J Me_ - — - - - <br /> L(AA1,, CA 9S3)0 Inspection Date 01a 1 o <br /> r ri P Time In Time Out <br /> Business Rep Title0 AM/1� C AM <br /> L/ J 0 PM Q V ® PM <br /> ---- - -- - Operational Status Tire Type 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) <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive I*Truck <br /> Longitude - Q Planned OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Auto Repair 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 /> 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 /> 0PRC§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 <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 /> -Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18459.3 <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers i Q Referred I CIWMB Enforcement <br /> QQ 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 0 ]� _ I , <br /> 1ASl C� <br /> Inspection Form Included: QI n l3 M; k <br /> Comments Included: QI ` LAE) <br /> Business Rep's Signature Phone Number Inspe is Signature - Phone Number <br /> Bu P 9 _- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: L 1 �, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink <br />