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Waste Tire Suey & Inspection Repors Inspection Report Number <br /> G fil.. State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 11 <br /> California Integrated Waste Management Board — e--k <br /> Bart A Survey __ <br /> P <br /> BLUE OR BLACK INK PEN <br /> asmessProfile.' Inspec(ion DtatJs <br /> -- 1 _ <br /> TPID- '�J Inspection Type (Fill one) <br /> Site Suffix: _ ! L)_ _1] ® Routine Q Re-inspection Q Referral Q Observation <br /> LLocal - - - - -- - - - If Referral,choose referral type(Fill one) <br /> Identifier: ��G`41O�\ q q( ' L U I_tf1 t, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �3 � � - � � rim � I Cl I <br /> Street <br /> Inspection DateLL= <br /> CoA�f CA <br /> City State ZIP Code Time In Time O-ut <br /> Business Rep Title O AM i AM <br /> .. _ _._. O PM .__� .. _....__, O PM <br /> r.'L�__ "s0— V),\I (.0 nk4- - -- - r- <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 6 Active Q Passenger Q Generator Q Outdoor <br /> Latitude ll Q Closed Q Altered <br /> GPSQ Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR 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 Q Agriculture Q Shredder 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 /> V <br /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB m FTI m <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q <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 /> - -------- <br /> 0 <br /> --Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 3; In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Ivr1 <br /> -_cu' t�x- c� —!` r��t f`� i TIr rr�,r t�� :t _ - <br /> Avce hco A\'n off—�� �--�-�» <br /> i <br /> Inspection Form Included: Q; <br /> Comments Included: 0: <br /> Business Rep's Signature Phone Number Inspector's Signature__ —'4 <br /> = Phone Number <br /> _ - -- I 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X � \/ ii_.; �dl j j <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />