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Waste Tire S— ✓ey & Inspection Repoi Inspection Report Number ■ <br /> ooa< State of California Il - 1127948 <br /> C IWM B 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 41 Inspection Type (Fill one) <br /> Site Suffix: I 3 O ) • Routine Q Re-inspection Q Referral Q Observation <br /> Local y, If Referral,choose referral type(Fill one) <br /> Identifier: 3cxV` �V� -�`�� ' `l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �^�`�5 `,\ Inspected By Inspector <br /> `_ V\5VZJ l'le� -- <br /> i l Q,Y I <br /> Physical Address �J l 1-�S p Art m <br /> ,aa\ Ghef6�ee. <br /> Inspection Date <br /> L CAQ 4 C) Time In Time Out I <br /> Business Rep Title O AM O AM <br /> I1UI'IC � � ©I.tlYlti✓ ? � g �PM - - -- � -.... � L� •PM <br /> UVIYYIL' �eGti^ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger Generator ® Outdoor <br /> 0 O Closed O Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude — O Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) _ <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 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 EXE <br /> O 014 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators @ In Compliance - No Violations <br /> 0 0 Other: § ------ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ( -- - -- <br /> Business Rep's Signature Phone Number n e nature _ Phone Number <br /> (� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X L X A1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ■ <br />