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LIS <br /> Waste Tire burvey & Inspection Report Inspection Report Number ■ <br /> State of California Il - 1143797 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> Califomia Integrated Waste Management Board <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - - - - <br /> TPID- ' � � � � � � _ � Inspection Type (Fill one) <br /> Site Suffix: I 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalC _1 If Referral,choose referral type(Fill one) <br /> Identifier: SQ(\ l J OCL k�n u,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `J Inspected By Inspector <br /> Ctn-_5VLlz_ Tn_kk UAC�n <br /> Physical Address &. l cotf <br /> Inspection Date a / l � � I b <br /> Time In Time Out <br /> Business Rep Title 0 AM0 AM <br /> PM 00 PM <br /> 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 /> Q Active Q Passenger IS Generator Q Outdoor <br /> 0 ® Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive •Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 1 A HAULING AND MANIFEST REQUIREMENTS <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting RequirementsDatem / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 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 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 /> Q Q Other: § <br /> Comments I r <br /> Q.o�hsv� ,na_(�xs�or e On is � app �0� ,t --l,�r�"Ow <br /> - - - 11 l <br /> o,Ci�� � 1uS _C�oSe ul_l�-fin QS\ck )A5. 00 `OteT irl VUS�S1Cg - — <br /> I <br /> Inspection Form Included: 0 (,,,� Q 1 <br /> Comments Included: Ql' (10�one <br /> Business Rep's Signature Rhone Number Inspe t is Signature Numbe� <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �( p 62081 <br /> -- -X -)IEA <br /> A <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py: ® ■ <br />