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Waste Tire Sup Bey & Inspection Repo, ii. Inspection Report Number M <br /> State of California <br /> ka 11 - 1143643 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey----—--- — — <br /> Business Profile - Inspection Details — <br /> _ Inspection Type (Fill one) <br /> Ste Suffix: '5 3 4111 Routine 0 Re-inspection 0 Referral 0 Observation <br /> --- --------- — --- <br /> Local � `� If Referral,choose referral type(Fill one) <br /> &. <br /> Identifier: Ln � u�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 3Z_ <br /> Time In Time Out `J <br /> Business Rep Title <br /> 0 O O PM G O PM <br /> Operational Statusi 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) <br /> ® Active 0 Passenger Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 /> 0 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 ®Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date® � <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB 6 <br /> (Required for NOV or EXT) <br /> 0 0 <br /> 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 /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § -- <br /> Comments <br /> Inspection Form Included: 0 -10 <br /> Comments Included: �ee *-ignat2,kres Phone Number I cto gnature ___ __Phone Number <br /> — - - -_ 62081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect: X e E AMP; l- E " <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />