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= Waste Tire Survey & Inspection Report Inspection Report Number <br /> State <br /> CIWMBf 81(New Survey Form - Page 1 I 1 - 1143552 <br /> CIWMB 181(New 04/04) Y <br /> California Integrated Waste Management Board - <br /> Part A_--Survey-- _ - - -BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- © ' Inspection Type (Fill one) <br /> Site Suffix: l 'S $ 5 2. 5 Q Routine Re-inspection Q Referral Q Observation <br /> Local ` t If Referral,choose referral type(Fill one) <br /> Identifier: Jam J Co��� Vu — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C vim.y cuss co, 3 - E <br /> Physical Address a <br /> Arlo <br /> s ild <br /> S-� Inspection Date O ~J <br /> �C' I—Grl CA 15-2o3 <br /> Time In Time Out <br /> Business Re Title AM AM <br /> P <br /> f � ( ' Q Q O PM I S O PM <br /> s ��o I s lt+�� - <br /> ---- a� - ------ - --<- <br /> Operational Status TireTypa 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 /> ® Active Q Passenger • Generator 46 Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned OTR Q End-Use # Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ; <br /> A I HAULING AND MANIFEST REQUIREMENTS <br /> ® <br /> ® Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <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 / IX I / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M5 M10 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q - - ---- <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 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments t 1 II ' �1 <br /> 1QSLt�4 �Ac. O(1_ lrh,S Ulu, c- (� VtOu�—�r���c� (9I1 <br /> --�17 I n) U,��1 -oft <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Bu ness Rep's Signature Phone Number 41nspes ' nature Phone Number <br /> Ir - <br /> --- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrectle X { A h <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: <br />