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1 <br /> ® Waste Tire rSu&y & Inspection ReporiL Inspection Report Number ■ <br /> State B California Survey Form - Page 1 I 1 - 1086933 <br /> CIWMB 181(New 04/04) y <br /> California Integrated Waste Management Board ' <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> -'' Inspection Details <br /> fPID- _ Inspection Type (Fill one) <br /> Site Suffix: —.1t _—_ z t Ill Routine Q Re-inspection Q Referral Q Observation <br /> Local C ` If Referral,choose referral type(Fill one) <br /> Identifier: �f <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ) i L& Ll I C <br /> if—.1L—L)r �J Fc <br /> Streetf Inspection Date �` T_ <br /> L____� <br /> Pity Title State Cif-'Crjr9e Time In C�� O AM Time Out 0 AM <br /> F2 <br /> Business Rep ) 40 <br /> Y f I Q PM A] : LPM <br /> Af ". <br /> —- — -. <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 /> i <br /> l <br /> It Active Q Passenger Q Generator Q Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS <br /> Q Hauler Q IndoorL — Q Inactive Q <br /> Truck <br /> Longitude - � Q Planned Q 01-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 Q Agriculture Q Shredder C 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 M / M / M <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 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 I CIWMB Enforcement <br /> Q Q I'I 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.,'' In Compliance - No Violations <br /> O Q Other: § <br /> Comments <br /> - T 1e- <br /> i <br /> 14 <br /> 4 , <br /> �_ !! <br /> Inspection Form Included Q" <br /> Comments Included: "~ -- - <br /> BusinessRep s SignaturePhone Number Inspellct is Slj�na u <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: I I e XIA PIL[El 1112131 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />