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�.a <br />a <br />Me ; Ye �i1S action �t•Inspection Report Number <br />M Waste y p pSlate of California 11 1127929 <br />CIWMB181(New 04/04) Survey Form - Page 1 <br />California Integrated Waste Management Board BLUE OR BLACK INK PEN <br />Part A - Survey -Details- _ -- . — <br />- <br />Business Profile Inspection <br />TPID - } Inspection Type (Fill one) <br />Site Suffix: ` t ®Routine Q Re -inspection Q Referral Q Observation <br />Local �^ \� �, / If Referral, choose referral type (Fill one) <br />Identifier: SC kVA ' C' C6Ch� �"�/y U ��, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />�i en Lv>n it - - <br />Physical Address ` F /� l ��jy�k) �i'}'( buie� <br />a1+0 tA. Clrt{,Y70)�Iee, L -Y-) <br />J <br />Business Rep <br />W <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />c q5 - <br />Title <br />-Title <br />CL'ne'r <br />Inspection Date <br />Time In <br />/ 0 <br />Time Out <br />0 AM 0 AM <br />1 0 ® PM d 41 0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />O <br />(Fill all that apply) <br />(Fill all that apply) <br />O <br />Inspection Date <br />Time In <br />/ 0 <br />Time Out <br />0 AM 0 AM <br />1 0 ® PM d 41 0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />® Passenger <br />® Generator <br />I& Outdoor <br />Q Closed <br />Q Altered <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Hauler <br />®Indoor <br />Q Inactive <br />® Truck <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q End -Use <br />ON Container <br />Longitude — Q Planned ® OTR <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />® <br />Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q <br />Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Comments <br />Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />spection Form Inclutpd: ® - <br />Comments Included: ® -- --- -- ---- <br />Busi ass Rep's Signature Pho umber Ins ct r' Si n tura Phone Number <br />----- - — -- - -_- INSTRUCTIONS ON BACK Correct. Incarrec / - 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink y: ■ <br />