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■ Waste Tire Su. ,ey & Inspection Report Inspection Report Number ■ <br /> tri State of California <br /> ` CIWMB 181(New 04/04) Survey Form - Page 1 Il - 1143610 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PE <br /> Part -Survey_ N__- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. (�� �� — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 1 l A-16'tso "WLW <br /> Inspection Date S / 0 <br /> Time In Time Out <br /> Business Rep Title ® AM 0 AM <br /> O 0 PM ` z 0 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 /> /v) <br /> • Active Passenger 4D Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude • Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 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 /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® 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 I HAULING AND MANIFEST REQUIREMENTS ® Notice Of Violation Q Extension <br /> Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> dQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ER / F/ I <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 DCT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 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 Q In Compliance No Violations <br /> 010 Other: § <br /> Comments <br /> Inspection Form Included: Q , <br /> Comments Included: 6j �J << / " _ -C� �.(/�✓�j�'J - �CI-�6�' 673 - <br /> ;'Business Reps Si ature Phone Number I e to ' g ature Phone Number <br /> INSTRUCTIONS ON BACK Cor ct: I orrect E A P' e 3 62081 <br /> __ <br /> ■ - _ ® ■ <br /> White Copy: IWMB Yellow Copy:Operator Pink Copy:LEA <br />