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Waste Tire Surty & Inspection Report Inspection Report Number <br /> State of California V 3 S 1 V <br /> :a9 COMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey - <br /> Business Profile Inspection Details' <br /> Inspection Type (Fill one) <br /> TPID- <br /> Site Suffix: ;j l r ' Q Routine Q Re-inspection Q Referral Q Observation <br /> Local } If Referral,choose referral type(Fill one) <br /> Identifier: , { Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LA <br /> Physical AddressL .tti Z— <br /> Lr <br /> StreetInspection Date <br /> A <br /> r 1, . ,.1 �? l Time Out <br /> ` State ZIP Code Time In <br /> y - -- 0AM 0 AM <br /> 4 PM F-P Fol__ - PM <br /> Business Rep Title RoT` <br /> --J t-- -- ---� Operational Status Tire Type Business Role Storage Type 1, <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 Q Generator Q Outdoor <br /> Altered <br /> 0 .. <br /> GPS Latitude —10 Q Closed Q Hauler Q Indoor <br /> LLI ---� _ Q Inactive Q Truck <br /> —T .O <br /> Longitude - —I , ��7_ R Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 QQ 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[I] m m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Q In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments i i v ` � ijlltl)It'.:i U_�c tta2f' :L_ <br /> i)r11 ;^qQY_At�_A 0 G-� C F� j# rw <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's. Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />