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Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ <br /> a State California <br /> �;. CaIWMBB181(New 04/04) Survey Form - Page 1 1 9 - 10 l 9 413 <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: ' 1 ` 1 9 Q j * Routine Q Re-inspection Q Referral Q Observation <br /> Local // If Referral,choose referral type(Fill one) <br /> Identifier: 5C(_u j,A-n GUl/n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> - <br /> �. <br /> ideg ��,us �� . - 0 1 Arm A by <br /> Physical Addresr3 9\ <br /> �1 Inspection Date <br /> Q5a�� Time In 6 Time Out <br /> Business Rep Title 0 AM @ AM <br /> � <br /> ��( O PM I C� Q PM <br /> ' �' �iv' ' Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active ® Passenger 10 Generator 4D Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude – Q Planned Q OTR End-Use Q 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 /> 7V ---AIHAULING AND MANIFEST REQUIREMENTS 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q -- —(Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 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 I CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § -- — -- - <br /> Comments f <br /> OWL MIP-ri/A <br /> 'Inspection Form Included: Q <br /> Comments Included: • <br /> B sines Rep's Signature Phone Number nsp 's S' In ure Phone Number <br /> — _------------- 620 <br /> 81 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �E'X 'A E 2 31 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />