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u Ve & Inspection Re O"Inspection Report Number <br /> Waste Tire S y p p � <br /> 111 State of California I 1 1143807 <br /> CIWMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- SUrVey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: I © I '0 Routine 19 Re-inspection 0 Referral 0 Observation <br /> LocalI / If Referral,choose referral type(Fill one) <br /> Identifier: SU(� JQ(( U t(� COlA (l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> +1 <br /> - -- - - - - <br /> Business or Facility Name I Inspected By Inspector r <br /> Wl (�0UC� Pale+S <br /> Physical Address <br /> loss ND(4 <br /> 5 - - -- -- - <br /> ] �j Inspection Date l V <br /> Sib c,vLA,D n (`A `Q S, Time In Time Out <br /> Business Rep Title J� 0 AM 1 AM <br /> 0 PM l 1 V V 0 PM <br /> OOperational 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 0 Passenger Generator 0 Outdoor <br /> 0 Closed 0 Altered N/ <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned OTR <br /> End-Use 0 Container <br /> Business Type (Fill all that --- <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other N 1l t <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXE <br /> 0 0 <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § - - <br /> Commentsf CC 101X5 1 11 Orm-u (nTaL'-N-�( <br /> t af`�1 . <br /> Inspection Form Included: 01 /'J- <br /> Comments Include <br /> 0 B es p's Signature Phone Number Inspector S natur P ne Number <br /> - -- - - <br /> - - -�- � I 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: '/�� l( .I X A P: 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :LE <br />