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_ = Waste Tire *Ay & Inspection Rep Inspection Report Number <br /> 11I State of California ■ <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1143821 <br /> California Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I "1 l S 3 �Q V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /� ` r If Referral,choose referral type(Fill one) <br /> Identifier: �tk � JQ(� utn `( (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Scs Skorc ��� S�c�t✓s q - D RcnPhysical ddress <br /> �M% <�, Mc�-\I'neA� AVe <br /> ����IU � !(V� I��� Inspection Date � � t) J <br /> t Time In Time Out <br /> Business Rep Title & AM AM <br /> Q 5 0 PM l 6 I 0 PM <br /> c - -- -- -� . -- -- - <br /> - - - - -- ( Y) ( apply) ( apply) ( apply) <br /> ---- ----- Operational Status Tire Type Business Role Storage Type <br /> Fill one only) Fill all that a I Fill all that a I Fill all that a I <br /> Tire Count(Whole/PTE) <br /> • Active Q Passenger ® Generator Q Outdoor <br /> Latitude O Q Closed Q Altered /11 <br /> GPS Q Hauler Q indoor /1 <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q <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 ENFORCEMENT STATUS <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 <br /> m / FTI <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / <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 l <br /> C�.� 011 1 �G-Cl�l _ (�� (�,c�1�n�1 ��--- �l_� <br /> Inspection Form Included: Q ;� Q -` e� �L10 - 33 &Q - J�_ �` <br /> Comments Included: Q JK/ 2 / VU�7 )" <br /> pusiness Rep's Signature Phone Number Inspect 's Signature "J hone Number <br /> L- - -- - - <br /> INSTRUCTIONS ON BACK Correct incorrect. X i1k- E X A P i 1 2 31 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: ■ <br />