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_ . Waste Tire Su, jey & Inspection Repo i Inspection Report Number <br /> tlBl State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I1 - 1127654 <br /> California Integrated Waste Management Board <br /> Part A_Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 11 ® I Inspection Type (Fill one) <br /> Site Suffix: I '"� p( Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: J001 1&1 n (1'�u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nameff Inspected By Inspector <br /> AM G Q, Pa Pa c if (brp. ? I _ I <br /> Physical Address J <br /> )533x; S, cl�►n �� A,��.. <br /> .L 4 r o p A �5 33� Inspection Date I ! 1 <br /> i Time In Time Out <br /> Business11Rep q Title (1\ O AM O AM <br /> rt.t� 1v�� ® PM O Is PM <br /> l yc -- - - - --- - -- -- -- _- <br /> ----- - - -- - ---- - - - Operational Status l Tire Type Business Role Storage Type <br /> 3 <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Passenger Generator ® Outdoor <br /> o .Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q 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 n <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other - 1�r�LL�o/,I <br /> Part B - Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility F ENFORCEMENT STATUS <br /> p Y <br /> V A HAULING AND MANIFEST REQUIREMENTS <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 Manifesting Requirements Date / / 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 ` ,1„�-, I._ I <br /> �v`.r.'►��dl,��� - LU�L� �"`�'S n ti�e(4;_ <br /> fc, �XC1\(Tfib GS11 rS _l 5 � —�l_ -Y 1 �-L�• <br /> Inspection Form Included: Q q, , 7� -7 <br /> Comments Included: Q !` 1 `�! - _ Z�1S -- _ _ �J'dWV`V J� I <br /> -- - _X*A <br /> -- <br /> - nBusiness Reps SI Hato ePhon Number Ispect s Signatur )hne Number-INSTRUCTIONS ON BACK Correct: Incorrect: E A M 2 3 62081 <br /> A�Z� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.L <br />