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Waste Tire Sfty & Inspection Repo" Inspection Report Number <br /> ■ -iii State of California ■ <br /> CIWMB181(New04/04) Survey Form - Page 1 I1 - 1140920 <br /> California Integrated Waste Management Board <br /> Part-A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I (� Inspection Type (Fill one) <br /> Site Suffix: I Cp l ` V (9 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: IS ' <br /> C(() UO Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busine s or Facility ame Inspected By Inspector <br /> uc lam. - _ <br /> Physical Address 0 <br /> X533 5� <br /> Inspection Date I 1 <br /> Aare C A g5ac�� 1 <br /> Time In Time Out <br /> Business Rep TitleO AM o O AM <br /> I ' � r PM PM <br /> - - - Q ---- -- -- 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 /> f Q Active Q Passenger Generator Q Outdoor <br /> - O 0 Closed Q Altered V v A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q 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 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder I&Other Wet(U 0(A <br /> - - - ll"ll„ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTSI F <br /> 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 <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> i <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 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Al14 K)o <br /> of S of a f (00( r l - — <br /> Inspection Form Included: Q <br /> Comments Included: ®I VRep's44�n�,t.r. <br /> sinPhone Number Inspec is Signature Phone Number <br /> - -- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 70X41L. E IJE3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />