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............... <br /> -..-_-_....--.. <br /> J <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> �= State of California 11 - 1143550 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey -- — — - - <br /> LB -___ Profile Inspection Details <br /> TPID- �f '"� - l Inspection Type (Fill one) <br /> Site Suffix: ` 5 h _ � r —0 l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� U �Vt l l(! Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> a t a cis j �( l <br /> Physical Ad�ss - <br /> /� / Inspection Date � ,C) ( f D <br /> //�� <br /> ",93- t6 Time In Time Out [ L/ <br /> Business Rep Title ��'y ` AM <br /> I '2 • � V 0'M l c2 C� ® PM <br /> ,(���Af1 Y - - -- —-- --- - - ------ <br /> Operational <br /> --- <br /> � tJr �i - ir- <br /> __ _ _ —�-- 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(Whole/PTE) <br /> � 0 Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® 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 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 Q Notice Of Violation Q Extension <br /> O 1 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q 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 /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § — — <br /> Comments <br /> SO <br /> Inspection Form Included: Y6,Y-- ?6 73- -- <br /> p O J7� <br /> Comments Included:® - I e i nat a Phone Number <br /> Busines ep Ignature Phone Number - <br /> - - - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' �, X <br /> - -- - -- ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: E <br />