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'A <br /> Waste Tire Su*y & Inspection Report Inspection Report Number <br /> '= State California <br /> CIWMB Survey 181(New 04/04) Y Form - Page 1 Il - 1088054 <br /> California Integrated Waste Management Board J - <br /> Part A- Survey_ BLUE OR BLACK INK PEN„ <br /> Inspection Details <br /> Business Prgfiae - —_- ----- <br /> - - .... . <br /> - -- -- <br /> TPID- ff Inspection Type (Fill one) <br /> Site Suffix: / J r' o Ll Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � .S� �lG� irl.(C<_G'�. lCg Gt4L' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - <br /> Business or Facility Name <br /> Inspected By Inspector <br /> CC <br /> Physical Address �— <br /> il <br /> street <br /> f'1 Inspection Date .r �- <br /> l___ —_ _ <br /> Time I,n <br /> Time <br /> Out ZIP Code <br /> Business Rep Title 1 O AM ( O AM <br /> f } I • ' � O PM 01PM <br /> 1_2 -,.�_'._...T:. ..,--.— 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 /> The Count(WholelPTEj` <br /> QActive Q Passenger Q Generator Q Outdoor <br /> _ — --- p Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR <br /> ji ,End-Use Container <br /> Y.J. <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 /> Vj 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 / Ffl <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 /> 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 FCIWMB Enforcement <br /> Q Q 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 <br /> Q Q In Compliance No Violations <br /> — - - <br /> Q Q Other: § ----.._.. -------- ------_- I <br /> Comments ' ,: ( ; C,. ( } t id r 1 l,} ( r 7 i✓ f( �i'. <br /> k 1 a <br /> t,`� J l 1 I <br /> =_ 11 l ) , l �l ll! <br /> r <br /> } .J <br /> Inspection Form Included. Q <br /> Comments Included: <br /> . r._ <br /> Q Business Rep s;~Signature Phone Number Inspector sAgnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X c �/ ,�1 A M P I L ETJ 1, 1 23 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />