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3_ Waste Tire S :y & Inspection Repo. Inspection Report Number ■ <br /> li•�i State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 Il _ 1127749 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C Inspection Type (Fill one) <br /> Site Suffix: ` �_ Q le Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> A�-6-, Priqux - �\. - <br /> C Inspection Date Z C) CJ O <br /> j i� <br /> Time In Time Out <br /> Business Rep Title ) 0 AM O 0 AM <br /> I I �• 0 PM PM <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) 55 <br /> ® Active Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®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 ® Other '�"c <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS l <br /> Q 0 - Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O __ --- <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/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § - - --- - ----- - <br /> Comments <br /> r <br /> ,Inspection Form Included: 0Comments Included: — <br /> JPnesAiillpG'sSl6nature Phone Number IrieWfo—r'__F.,§Icjfiature e Phone Number <br /> - �1 62081 <br /> INSTRUCTIONS O ACK [Correct:* Incorrect: X i\� E XL 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: <br />