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® == Waste Tire Sup vey & Inspection Repoi .. Inspection Report Number ■ <br /> ria State of California I 1 - 1144044 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> P^rt.A_-_Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> _ - - <br /> PID- Inspection Type (Fill one) <br /> Site Suffix: t Routine Q Re-inspection Q Referral Q Observation <br /> Local �� � r �� If Referral,choose referral type(Fill one) <br /> Identifier: l C'��► l 'vc Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name {� Inspected By Inspector <br /> 62u ts 79% <br /> Physical Address <br /> t1Mc ­7 Inspection Date � � t 5- � 1 <br /> Time In Time Out <br /> Business Rep Title ] ,/ ®AM / 2 I'AM <br /> l rl 7 0P ( j ze J 0P <br /> oc rt, <br /> ---- — ---- — - -- — - perational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Qinactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> „ 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 40_S � JOLib4�/n 46nY ✓ <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 QQ Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / 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 O - - ---- <br /> 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § —_._.. <br /> Comments <br /> �.. pection Form Included: Q7,5 <br /> q <br /> Comments Included: ® - - - <br /> Business ep's Signa r Phone Number In a is g ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect �i E A MiL E f C <br /> White - -- ■ <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />