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= Waste Tire Su,. ,y & Inspection Report nspection Report Number ■ <br /> California <br /> CIWIVIB 181(New 04/04) Surve Form - PatuYe 1 I 1 - 1140846 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey_ __-- -___-. - - BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / �y Z - O ' Inspection Type (Fill one) <br /> Site Suffix: ` ! Q Routine ® Re-inspection Q Referral Q Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: ec �� 2G{,L( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address , ¢= �ue [.IGti'f' C,r�✓ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep / Tit[�ry ® AM f 0 AM <br /> YItSN1Y� ��Ll f �Vi'tL{�GYIf I 0 PM / 0 PM <br /> J L1,Y► �lhS�'► 1/l GC f�IZfirG�fi1.�- -- -- -- - --- <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ® Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use ® 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 d Tie <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 1 Q 1Other: § <br /> Comments <br /> WCI�LF-lQ� T <br /> Inspection Form Included: Q� X � T Zg> ybl" 4 2- <br /> Comments Included: "V - -- - - - — ---- <br /> Business Reps Signature _ Phone Number pe�natur Phone Number <br /> G, 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X A!, ",,k <br /> P I 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator :L A ® ■ <br />