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= Waste Tire ey & Inspection Rep Inspection Report Number ■ <br /> l ate State! of California <br /> CIWMB181(New 04/04) <br /> I1 1127685 <br /> California Integrated Waste Management Board Form - Pay1 <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' —1O 4 5 - ^ IInpection Type (Fill one) <br /> Site Suffix: v Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: \ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I <br /> Physical Address 3 <br /> 0 Inspection Date l 1 O <br /> Time In Time Out <br /> Business Rep Title AM O AM <br /> a PM <br /> `L)loIh ,/'if,� r\e '--n a"—ner 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 (Whale/PTE) <br /> t 5 ®Active ® Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <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 /> (a 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 HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 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 O <br /> 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments M . <br /> -- /V0 cy &rA6 <br /> Inspection Form �nc <br /> ncluded: 0 <br /> Comments luded: 0 I — c <br /> Busine s e ignature �_.P one Number t S tore Phone Number <br /> INSTRUCTIONS ON BACK Correct:, Incorrect: §� IR X A L I 112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: ® ■ <br />