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Inspection Report Number <br /> .... Waste Tire Survey & Inspection Report <br /> 11 <br /> I State of California <br /> CIWIVIB 181(New 04/04) 1143453 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Ll 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: -sc"rAl ��N""Tvv cowJ"I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address lc) IS L A <br /> i� <br /> Inspection Date a 3 is <br /> CIA 9 L Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> V.J,- 0� ti.."twitutrv"r I Z-1 0 0 PM l '5 9 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 /> 6 QF Active 0 Passenger 40 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> Longitude 0 0 inactive ®Truck 0 End Use a Container <br /> 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 A_THAULING 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. 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 <br /> M M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 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/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 0 in compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> Lvyv� <br /> Inspection Form Included: 0 <br /> Comments Included: (D - <br /> I siness Rep's Signal Phone Number ns c ct s Sig tur Phone Number <br /> mur <br /> INSTRUCTIONS ON BACK correct: Incorrect: IE X1 1 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink <br /> Copy. <br />