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' <br /> Waste Tire Sui ;y & Inspection Repolei= <br /> State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 � 0 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( t y lJ 3 13 I I 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local \" l If Referral,choose referral type(Fill one) <br /> Identifier: IS 6 , t _► I ( ibu — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �J ' ' I� Inspected By Inspector <br /> ysical OWdre,s l D� <br /> Street � M06 <br /> (�/�, � �,�J Inspection Date / � � � L Oc — ��— ioC000 Time In Time Out <br /> C/ry State G. Coa.. <br /> Business Rep Title `I C Q AM Q AM <br /> '-- —1-- � PM � � �j � PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 5 <br /> 9 Active O Passenger d§ Generator I* Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler O Indoor <br /> — . - O Inactive ®Truck <br /> LongitudeQ Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Other If -�tbn �i n U� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STgTUS J <br /> V A ' HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q E <br /> O Oxtension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date O / a <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 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 Q Referred 1 C-IWMB Enforcement <br /> Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __-- <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> O 0 Other: § <br /> Comments Gl{l �-IJU4S—�1D_ <br /> 1. �'c V;a14'►c��4_ CU2 I��( . - T 1 erc�n_a- or�o _arno�,nk� <br /> ,b a Q 0LI) 0 P ei_111_ —k _n _ �C1 le� D�1_0�- <br /> dl <br /> Inspection Form Included: Q [�j �/ J Q <br /> Comments Included: 2 - `� j�-03Qz — —�� 17�+ <br /> Business Rep's Signature Phone Number Inspe or's Signature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct: I correctIX A Ah P� 1E A 1 21 <br /> White Copy CIWM Yellow Copy:Operator Pink Copy:LEA <br />