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Waste Tire <br /> ...Arvey & Inspection Repi, Inspection Report Number <br /> 3 State of California <br /> CIWMB 181(New 04/04) Survey Form o page 1 I 1140971 <br /> California Integrated Waste Management Board <br /> UE RC IN PEN <br /> p-�A-Survey---- --- ------------ ----- ------- -- <br /> iness Profile Inspection Details PID—Inspection Type (Fill one) <br /> Site Suffix: ' { 4J L Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `�C,l�f� ✓��L ✓ �C`Lh-L+9 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address lc !`i �1►�1,: 1�✓• <br /> Me <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title (/ ��, &AM ) / AM <br /> V G V 0P / ' ! f� QPM <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) 9 9 <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> O ® Closed Q Altered 4,14 <br /> GPs Latitude All',4 Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude m Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New 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 (a Other (t-,AU,ke, ,r <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V Al HAULING AND MANIFEST REQUIREMENTS <br /> I 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / FP <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!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 ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> (f e, tee° <br /> I.,spection Form Included: Q -t,19 —e3 6 tn � 73 <br /> Comments Included: -- ----- -------- -...-------- - --- -- ----Business Rep's Signature Phone Number Ire Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />