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..... ............. <br /> Waste Tire Survey & Inspection Repoi i inspection Report Number ■ <br /> State of California Survey Form - Page 1 11 - 1144017 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board BLUE ORBLACKINK PEN- <br /> Part A- Survey <br /> Inspection Details <br /> 'Business Profile <br /> _TPID- - Inspection Type (Fill one) <br /> Site suffix: 5 0 o� D * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 <br /> Inspection Date <br /> exZl <br /> Time In Time Out <br /> Business Rep Title 0 PM 0 PM <br /> j)Cj 1`0 )l / / A <br /> - : r, - Q "M I- z -: o -&- M <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 /> Tire Count(Whole/PTE) Active 0 Passenger ® Generator d Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 inactive 0 Truck <br /> Longitude 0 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 /> 10 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 1, 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0Date <br /> 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> ,1 ,114 CCR§18459.1 -Tire Program ID Number from CIWMB m / m / m <br /> 0 0 (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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in compliance No Violations <br /> Other: § <br /> Comments <br /> f ------ <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Comments I e tor' gnatu Phone Number <br /> Business Rep's-Signature Phone Number UT <br /> 62081 <br /> Incorrect: X E X A P L <br /> INSTRUCTIONS ON BACK Correct: <br /> Cop <br /> Pink ® r <br /> ■ White Copy:CIWMB Yellow Copy:Operator Cop <br />