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■ Waste Tire Sui vey & Inspection Repor, Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 11 - 1127933 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey___ <br /> Business Profile Inspection Details - --- - — <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: 1 ` ` O I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: an J 0uf�U.6 (A74 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> &�its IT i r0-1 I cl ql cr <br /> Physical Address ! � �5 C,& <br /> --)` <br /> Q Inspection Date { � I L4 � 1 <br /> "��� Time In t Time Out <br /> Business Rep Title 40 AM u AM <br /> ` l O O O PM I l O PM <br /> AIIA01-sAt c <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) <br /> Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed 1 Q Altered <br /> GPS Latitude P/ Q Hauler Q Indoor <br /> O Q Inactive Q Truck J� <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Qw Q Retreader Q Tire Derived Fuel <br /> NeTire Q Government <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 ® Other �s��(/j�'�4,' <br /> arra-arra-- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 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 I 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 In Compliance - No Violations <br /> Q Q Other: § ], �,- -1 --�-- -- <br /> Comments �Uul 1�- 11J A•S n <br /> 10\w _rn_U)(A's - IYACca - -- arra-- - - -- <br /> d t Ja i�11,s of a fru- j 0n�c n, — <br /> Inspection Form Included: QII - /��, � �0�P��® 4-e- <br /> alp-11 <br /> ��`� �Comments Included: ® �''T - p�p's Signature Phone Number is Signature Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 3# <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />