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■ io <br /> Inspection Report Number <br /> z- Waste Tire Survey & Inspection Repc.. . <br /> iii State of California I 1 - 1140913 <br /> CIWMB 181(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 Ins ection Details <br /> p <br /> TPID- �] Inspection Type (Fill one) <br /> Site Suffix: f - ,� .1.. ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: x l Vtir �� /y1,i`Z�j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phy ical-Address I = � � � � � ���Tn� A.,,-cvn ja,Itt, <br /> 6-i(3 ( E . t;lqe,(-v t e-e, <br /> Inspection Date <br /> Time In I Time Out <br /> Business Rep Title ®AM — ®AM <br /> • �S Ce 0P 5 OPM <br /> L --- Storage Type <br /> Operational Status Tire Type Business Role <br /> -- -— - - <br /> ti (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active ® Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Is Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 0 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 A HAULING AND MANIFEST REQUIREMENTS <br /> 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 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 Q 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> e <br /> Inspection Form Included: Q <br /> �j ,rye (�' � ,'7 _... �<� c�,G <br /> Comments Included: ® B" ���-��/�/-� � `G/T� <br /> - rf <br /> u mess Rep's Slg ature Phone Number Insp is g ture Phone Number <br /> _ - - --- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X �i V, e X AM Mof r i <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy <br />