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r <br /> Waste Tire Sutey & Inspection Reporlp Inspection Report Number <br /> ® ii - 1144026 <br /> 8C88I:. Slate of California Q 1 <br /> 8 CIWMB181(New 04/04) Survey Form - Page ■ <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A_Survey_ <br /> - - <br /> ness Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Ste Suffix: ` b l lJ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �F- ,, If Referral,choose referral type(Fill one) <br /> Identifier: �-E�� 1 K Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph��ys22lca A dressc mac. p <br /> c7`� `�• +Y l it C� . <br /> l � �'( 6 Inspection Date <br /> �1�7C�'✓1Time In Time Out <br /> Business Rep Title AM <br /> Q AM ...� <br /> 0 ® PM n PM <br /> Olti )0� C' Operational Status Tire Type Bu7apply) <br /> torage Type <br /> (Fill one only) (Fill all that apply) (Fillill all that apply) <br /> Tire Count(Whole/PTE) l/lQ Active ® Passenger ® Outdoor <br /> O ® Closed Q Altered / <br /> GPS Latitude Q Hauler Q Indoor / <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) — - <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> QService Station Q Hauler Q Agriculture Q Shredder ® Other hlu,r� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> ' A HAULING AN`D MANIaste FEST <br /> Rr (eRratMEandS Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§q 95 <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 /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 Q Other: § <br /> Comments _ <br /> Onspeclion Form Included: Q f! , 73 <br /> Comments Included: ®, — <br /> kness,Re s Si nature) Phone Number ( p to n ue Phone Number <br /> - — - 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />