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Waste Tire Su. :y & Inspection Report Inspection Report Number <br /> State of California I 1, 1088090 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Sury <br /> -FBLUE OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> TPID- � � _ Q Inspection Type (Fill one) <br /> Site Suffix: 1 1& Routine Q Re-inspection Q Referral Q Observation <br /> LocalC - ^ If Referral,choose referral type(Fill one) <br /> Identifier: 1 �c �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �c�m P cJ � 'U n <br /> Physical Ad ress <br /> Inspection Date 4q Q Z Q <br /> mrcm�r 533(, J <br /> Time In Time Out <br /> Business Rep Title 0 AM 0AM <br /> Q <br /> ® PM 3 3 ® PM <br /> I—� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger &Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck i <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> r V A HAULING AND <br /> MANIFEST REQUIREMENTS <br /> - O Notice Of Violation Q Extension" <br /> "'�, <br /> 0 <br /> 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 1 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 Retention of Comprehensive <br /> p Logs for 3 years <br /> Q Q -14 CCR§18460.2 Manifest System Requirements tsfor Registered Waste Tire Haulers _Q Referred/CIWMB Enforcement <br /> i <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q - em e In Compliance - No Violations <br /> Q Q Other: § f - <br /> Comments 'r'ym? qn- 1k{�. C1C.��('_ CtV�� 1 Yl>° 1nt(Ow i'y1C; e1r, <br /> lq'kc) ca /hy 1 rv►� . <br /> 4b �P S rico P 6cJc� r S{'ay e�?ma s t �'G A]o V) �c,.�2 i s /Alo 46CJ <br /> Inspection Form Included: Q <br /> Comments Included: QB <br /> B si ep's cSig ture Phone Number ' lnspe I s at re - Phone Number <br /> INSTRUCTIONS ON B CK JAIMIPILIE1 1112_ 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />