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Waste Tire Su. ,ey & Inspection Report Inspection Report Number <br /> State of California 11 - 1127945 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I L( - Q 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� /+ If Referral,choose referral type(Fill one) <br /> Identifier: A y` �,X.X.l%viNr t-ftJYL/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U / Inspected By Inspector <br /> Physical Address C� �'tKtYYt�c �GL <br /> Inspection Date /r) �� t <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> / ' 0 ® PM J 3 O PM <br /> r 'o -- -- Operational Status T 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 /> a Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR 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 /> {� 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 ric i 6f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j AHAULING AND MANIFEST REQUIREMENTS <br /> j Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> I <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> Q Q 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 Q 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 Q Other: § __— <br /> Comments <br /> Inspection FormIncluded: Q �/�„Jy 9� „ <br /> Comments Included: <br /> ®i.. �� G�' <br /> n�se, 'Allnature lll... Phone Number In _ct Signature _ Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: i P 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:L <br />