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�9L82fj4022.6 <br /> == Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B 181(Now Survey Form - Page 1 I I 1 - 1108401 <br /> CIWMB 181(New 04/04) �/ ((''�� i <br /> Callfomla Integrated Waste Management Board ) .J L <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , IT I Inspection Type (Fill one) <br /> Site Suffix: f 116 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: i � ✓l_T7a Q Q Q P Q Q Other <br /> U 1 [Q) CHP CIWMB Complaint Educational Visit <br /> Business or Facility Name Inspected By Inspector <br /> Physics Address <br /> Street <br /> Inspection Date I I o I� 10T" 9 <br /> Cily Stats Z!P Code Time In __ Time Out <br /> Business Rep Title <br /> - 1 ^;O AM �� ,j I Q AM <br /> �/ <br /> ® PM I ' IO I ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f ®Active ®Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned ®OTR Q End-Use Q Container <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I E N Qe.RCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice t?f 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 <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 or NOV or FXT) <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 C-I MB En orcement <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 /> 1010 Other: §�_ l <br /> Comments DJ (� MSD t°_c1 r\\ m e 07A �� �� Q.✓l C� �� <br /> l�d v I��c..Tl�'tS ar �lAJ a�" �ar)G�✓✓� <br /> Inspection Form Included: Q C �7757/ <br /> Comments.Included:Q OIlJ--4- "" Z <br /> slness Rep's Signature Phone Number Ins 9ts.S a Phone Number <br /> INSTRUCTIONS ON BACK e e FEIXIAIMIPILIEIe1 2 3 62081 <br /> White C y.Cl Yellow Copy:Operator Pink Copy-,LEA <br />