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:'3- <br /> Waste Tire Sup Bey & Inspection Repori, Inspection Report Number ■ <br /> -11 State of California 11 - 1143827 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board - -BLUE OR BLACK INK PEN <br /> Part A-Survey___ <br /> Business Profile <br /> Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: l 0 J G l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> �p; <br /> Identifier: A L `r�nt, (L�-v/L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Address <br /> Inspection Date 112 Z 1 Q <br /> 1 v� Time In Time Out <br /> Business Rep / Title / ) 0 AM - /Y� ® AM <br /> 0 1 � O PM I O PM <br /> _v _ �� co <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 Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O <br /> Q Inactive ® Truck <br /> Longitude - Q PlannedQ OTR Q End-Use Q Container <br /> _ -- ------ __J -- - - - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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-1 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 /> 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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <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 /> Q iQ 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers i 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 - �cw417i <br /> C1Y 0s <br /> iInspection Form Included: Q <br /> Comments Included: 01 <br /> i - - <br /> Susi ess Rep's Signature Phone Number In tor' nature Phone Number <br /> - --- ----- 62081 <br /> 12131 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect i `J �/I X + t <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: ® ■ <br />