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Waste T re 5 y & Inspection Re port Inspection Rep�ort lum <br /> ber <br /> State of California <br /> CIW <br /> MB 181(New 04/04) Survey Form - Page 1 9 4 <br /> I <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I • 5 © ' ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` t If Referral,choose referral type(Fill one) <br /> Identifier: 10 C11 14 M (011Ani� 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address \, l en GS co U <br /> 0W �� I-J f J�r1Gtt,!✓� �1 <br /> '4l ' C L J Inspection Date 0 3 / I <br /> 0 11z``D r-a <br /> Time In Time Out /`� <br /> Business Rep Title 1 O 0 PM I 3 / 0 PM <br /> ��un SOtt U_JD �i5pak�r t' <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � 9 d <br /> 0 Active 0 Passenger ® Generator @ Outdoor <br /> O Q Closed 0Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive I* Truck <br /> Longitude — Q Planned OTR End-Use ® 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 /> Q 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 /> 0 0 Other: § <br /> Comments <br /> S2R. COttfiM4 S 'afM <br /> Inspection Form Included: 0AA <br /> Comments Included: ® -- <br /> Bu iness Rep's Signature Phone Number Inspec s Signature Phone Number <br /> IEL 111213 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: ,/( N)� ,+i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co fL� &A 0 <br />