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Waste Tire Sup Bey & Inspection Repor Inspection Report Number <br /> State of California 11 <br /> - 1143768 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> califomia Integrated Waste Management Board <br /> PartA-Suryey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: y 1 V O I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Safl f) (,Ou( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> .LnteC(l ski U n U.`� ��e f � � ES C�� <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O a PM S A PM <br /> Business Role Storage Type <br /> iA � m C- Operational Status Tire Type <br /> 9 -- <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) � � <br /> 40 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered NIA <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned �OTR O End-Use Q Container <br /> Business Type (Fill all that apply) ' <br /> Q New Tire Dealer Q Auto Repair Q 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 Other P r C�mn <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation O 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 /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl / � / 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 /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q O 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 <br /> -14 au S b r (c CSI C�ICY�C C1 <br /> �is <br /> Inspection Form Included: Q; ' <br /> q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe 's Signa ure Phone Number <br /> - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct , Incorrect: X M �- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: <br />