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Waste Tire Sw vey & Inspection Repo, Inspection Report Number ■ <br />State of California I 1- 1144032 <br />CIWMB 181 (New 04/04) Survey Form - Page 1 <br />California Integrated Waste Management Board <br />'art A -_ SurveT_ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -i � I -7 � � � - ry � Inspection Type (Fill one) <br />Site Suffix: t (J I& Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier:( �t,�tvl �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />�� d - ►� Gj - p 1 A-(�uo t�ZZm bol <br />Physical Address <br />Hw cc p CA <br />Business Rep Title <br />rcApe -/)Uy_CLt_ l --- Fled rkk+'. <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />Inspection Date <br />Time In <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet U Government U Retreader <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 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V li A HAULING AND MANIFEST REQUIREMENTS <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 />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 <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 <br />0 1 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 1 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § <br />Comments <br />a_; � - / /0 <br />Time Out <br />�ry 0 AM <br />•� QPM <br />CAM <br />10 PM <br />Operational Status Tire Type <br />(Fill one only) (Fill all that apply) <br />Business Role <br />19 <br />0 Active ® Passenger <br />0 Closed 0 Altered <br />O <br />O <br />0 Inactive 0 Truck I <br />0 Planned 0 OTR <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet U Government U Retreader <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 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V li A HAULING AND MANIFEST REQUIREMENTS <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 />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 <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 <br />0 1 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 1 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § <br />Comments <br />a_; � - / /0 <br />Time Out <br />�ry 0 AM <br />•� QPM <br />0 Hauler <br />0 End -Use <br />0 Indoor <br />0 Container <br />Dismantler 0 Tire Derived Fuel <br />[ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />4PIn Compliance - No Violations <br />ction Form Included- <br />lnsPeComments Included: / 4eR <br />(� �7 S _ - _bG �y�-`'cv7Buslneeps Stgnatu Phone Number/ I p for �gn.ture Phone Number <br />. - - _ vEX[ <br />- - 20 -- <br />- - - 62081 <br />INSTRUCTIONS ON BACK Correct:* incorrect. X io } � M P i LI El It, 12 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />Storage Type <br />Business Role <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Generator <br />0 Outdoor <br />0 Hauler <br />0 End -Use <br />0 Indoor <br />0 Container <br />Dismantler 0 Tire Derived Fuel <br />[ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />4PIn Compliance - No Violations <br />ction Form Included- <br />lnsPeComments Included: / 4eR <br />(� �7 S _ - _bG �y�-`'cv7Buslneeps Stgnatu Phone Number/ I p for �gn.ture Phone Number <br />. - - _ vEX[ <br />- - 20 -- <br />- - - 62081 <br />INSTRUCTIONS ON BACK Correct:* incorrect. X io } � M P i LI El It, 12 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />