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-- -------- <br /> ...... .. .. <br /> ................. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ I State of California 11 - 1143662 <br /> FI <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK P E N <br /> Part A- Survey_ <br /> I inspection Details <br /> Business Profile-- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / 7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,CHP choose referral type(Fill one) <br /> Identifier: 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 6 <br /> Business or Facility Name Inspected By Inspector <br /> re <br /> Physical pE9ddress <br /> Inspection Date 0 7 <br /> Time In Time Out AM <br /> Business Rep Title 0 * AM <br /> 0 PM 7 7 0 PM <br /> B <br /> Tire Type I e Storage <br /> a Type Operational Status ' In <br /> (Fill alglthat'yacp <br /> (Fill one only) (Fill all that apply) (F ply) <br /> Operational <br /> (Fill <br /> one only) <br /> Status <br /> ni Y) <br /> Tire Count(Whole/PTE) Active Passenger Generator Outdoor <br /> 'v <br /> 0 0 CI <br /> Closed 0 Altered 0 Hauler 0 indoor <br /> 0 i <br /> GPS Latitude 0[ <br /> G 0 0 Inactive 0 Truck <br /> 0 0 End-Use 0 Container <br /> 0 Planned 0 OTR <br /> Longitude <br /> Business Type (Fill all that apply) <br /> New-fire Dealer 0 Auto Repair o-- Truckin <br /> *Aut -- gFIet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS. <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> M <br /> 0 0 114 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 �14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I ----- ——_--- <br /> --- <br /> - - <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance - No Violations <br /> 0 0 Other: § <br /> W ' - / <br /> Commentsn ']' <br /> OE <br /> J <br /> AW 41�--IYIA <br /> Inspection Form Included: 01 <br /> Comments Included: LA400 <br /> O�Business Rep's Signature PhoneNumberInspector' _ ignatur Phone Number <br /> 62081 <br /> F <br /> INSTRUCTIONS ON BACK I Correct:* incorrect: Y)]JE X1 A �JPJVEI I 2 3j <br /> White Copy:CIWMB Yellow Copy:operator Pink C.VEA <br />