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Waste Tire Su. vey & Inspection Report Inspection Report Number <br />State of California I 1 - 1143831 <br />CIWMB181(New 04/04) Survey Form - Page 1 <br />California Integrated Waste Management Board <br />Part A <br />- BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: �-j ; 1 O 1 19 Routine Q Re -inspection Q Referral Q Observation <br />Local / If Referral, choose referral type (Fill one) <br />Identifier: Scan JGC� c.n'Y1 C f-l�! Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By <br />UAL-- ye'o cvq - <br />Physical Address I l Q <br />4i760 e _ r-'lct✓i;DcaSe,-,_ <br />0C / <br />Business Rep <br />Inspector <br />i 4mm <br />Cc -11- g5oq� <br />Title <br />, r4ca-i-m G F <br />Tire Count (Whole/PTE) f <br />GPS Latitude <br />O <br />Longitude - <br />Business Type (Fill all that apply) <br />Inspection Date <br />16 / 1 O <br />Time In Time Out <br />9 AM' IOAM <br />O PM ! O G l O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />4k Active <br />Q Passenger <br />® Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />®Indoor <br />Q Inactive <br />®Truck <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet U Government U Retreader <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 <br />VA HAULING AND MANIFEST REQUIREMENTS <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q 1 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 <br />Q Q 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Q 114 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <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 <br />Q Q Other: § ,, ff <br />Comments 0 1, _ _ _ - - - -t-,,. J)_ I' � .An sy �. a -,n •-i'l/1 <br />l� <br />Inspection Form Included: 4Busin <br />�r los 3 <br />(O <br />Comments Included: - Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK <br />Correct: I* Incorrect X <br />-- <br />■ White Copy: CIWMB Yellow Copy: Operator <br />1. <br />Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS 1 <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m /m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />lature Phone Number <br />2131 <br />62081 <br />i-1, <br />