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Waste Tire SL-_ .ay & Inspection Repoi Inspection Report Number <br /> State of California I l 1127906 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA-Surve —_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - - -- <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: I - C V O a d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `�C�J�I � t�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l C A l iQ -_.1_ ,j_ <br /> �e 7 Inspection Date � � I � � ) <br /> LC'L�� (A q,533c) Time In Time Out t <br /> Business Rep Title I&AM I #AM <br /> 1 0 • 3� 0 QPM � I C.� � 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> P <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) VyJ <br /> Q Active Q Passenger 0 Generator Q Outdoor <br /> O )Closed Q Altered 41A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive � ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q 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 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 <br /> 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 ®In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> Inspection Form Included: 0^ / <br /> Comments Included: ®�V_ - -Z(Wel LOQ �S8 513.- ----- E—"may '�`— <br /> Business Rep's Signature Phone Number �tor's nature Phone Numbe <br /> - -- -.. <br /> - --- - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X + �/! 1 E X A L 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy <br />