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- --------- <br /> =tear--------------I <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stat of California <br /> CIWe1B 181(New 04104) Survey Form - Page 1 Il 1143548 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- <br /> Inspection Type (Fill one) <br /> '5 Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: G60 i V'\ CC>._/n'fV 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physic I Addrefs <br /> CA (75'3oc� Inspection Date <br /> Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep Title 0 *PM PM <br /> hober4- 6etv_"e t <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) 1 0 ® Active #Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive 0 Truck 0 Hauler Is Indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 New fire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government <br /> 0 Used Tire Dealer 0 Auto Body I@ 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 Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42153-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> 0 1 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date mM 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> t) <br /> Inspection Form Included: G <br /> Comments Included: Bu ess p's Signature Phone Number P40 s gn a Phone Number <br /> 081 <br /> INSTRUCTIONS <br /> TPI IrTI(jtj' ON <br /> C I XrA'. !-(Al 1112131 <br /> STRUCTIONS ON BACK orrect:0 Incorrect: X <br /> py, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink V N <br />