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Waste Tire SAbby & Inspection Repors Inspection Report Number <br /> 0 <br /> State of California <br /> C=B 181(New 04/04) <br /> ka f W - .- 3 <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board - BLUE OR BLACK INK PEN <br /> Part A- Survey BLUE------ <br /> tjoirt.Detal S <br /> Business <br /> 1- ' <br /> Inspection Type (Fill one) <br /> Site Suffix LO j <br /> TPID- Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'E, o q L <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Y"Y7 1uoAj <br /> Phys�"ical Address <br /> Street Inspection Date <br /> Time In Time Out 0 AM <br /> city Slate ZIP Code <br /> Business Rep 0 AM <br /> U C\ Titl <br /> 0 PM <br /> LAA <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that app y) <br /> 3 11) Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> EJ-] - <br /> F_ F ,,O 0 inactive 0 Truck 0 End Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 1, A HAULING AND MANIFEST REQUIREMENTS 0 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. <br /> Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / M / M <br /> 0 0 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators @ in Compliance No Violations <br /> 0 0 Other: <br /> Comments <br /> !J <br /> 1/A2Ai1 <br /> 4 <br /> Inspection Form Included: 0: <br /> Comments Included: 0: <br /> Business Rep's Signature Phone Number Inspector's Sig-nature PhoneNumber <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1�1 [i;K1 A M=� C 1-112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />