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. . ... . ..... . .................... <br /> ------ . ........... <br /> ------------- -­ --------- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California 11 - 1143786 <br /> C,WM13 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACKINKPEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- <br /> Inspection Type (Fill one) <br /> Ct ) I <br /> Site Suffix: C 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �w) (CkA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Inspected By Inspector <br /> Business or Facility <br /> Physical 'Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title *AM ®AM <br /> 0 PM L L 1 OPM <br /> Operational Status Tire Type Business Role I Storage Type <br /> 19, 00 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ' � <br /> Active Passenger Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> PS Latitude 0 Hauler 0 indoor <br /> G <br /> 0 0 inactive *Truck <br /> Longitude 0 Planned 0 OTR 0 End-use 0 container <br /> Business Type (Fill all that apply) <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 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 1 0 0 PRC§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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 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 0 Referred CIWMB Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 <br /> ®In compliance No Violations <br /> 0 Other: § <br /> Comments 161 C 1 <br /> L <br /> j J2Lj <br /> Y� AA <br /> �L wq n <br /> Inspection Formncluded: 0 <br /> Comments �ncluded: 0 pe e <br /> Business Rep's Signature Phone Number <br /> I ig ature Phone Number <br /> ___-_ - -.=-- - E.6 X A 2 3 62081 <br /> "I� �1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X / <br /> White Copy:CIWMB Yellow Copy:operator Pink op <br />