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M Waste Tire Su. ✓ey & Inspection Repor�. Inspection Report Number ■ <br /> s;$, <br /> 0State of California I 1 - 1143579 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> -t A-Survey _ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> I PID- � � � � � - O Inspection Type (Fill one) <br /> Site Suffix: ' O Routine Q Re-inspection Q Referral Q Observation <br /> Local �� � If Referral,choose referral type(Fill one) <br /> Identifier: 1/1, �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Wixrf <br /> t ;-; .h _ ¢¢�� <br /> Physical Address V <br /> Inspection Date ZJ <br /> Time In Time Out <br /> Business Rep`I Title 1 ;+ O AM I / } O AM <br /> �e / <br /> af� V�.�eZ �I'1r5 � l Z- G.- C� O PM 1-- - " CPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> O ® Closed Q Altered All/ <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ®OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) ` rJ - <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 � / ti6- e,C,t <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _V1 A 1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> 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 /> i <br /> O Q -- - __ <br /> 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 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 40 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ...pection Form Included: Q <br /> Comments Included:®/! �,gnatre <br /> Business RepPhone Number _Ins is 1 ature.— _ Phone Number <br /> - r - 0 - — /� � _.1.� —62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: j 3� fk P �. E <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />