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all Waste Tire Su y & Inspection Report nspection Report Number <br /> '1( State of California <br /> CIWMB 181(New 04/04) Survey Form - Page <br /> e 1 I1 - 1141292 <br /> California Integrated Waste Management Board y <br /> Part A- Surve_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Suffix:Site 0 t� ® Routine O Re-inspection O Referral O Observation <br /> Local 11 ► If Referral,choose referral type(Fill one) <br /> Identifier: {r �� O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name l•� <br /> .� Inspected By Inspector <br /> Lem c:VLk)Ckk f &-1,11hf ✓ <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title _ 0 AM 0 AM <br /> l{ice ® PM b/ 1 PM <br /> �e -- A'-- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / ) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �/ o ® Active ® Passenger ® Generator O Outdoor <br /> O O Closed O Altered <br /> GPS Latitude ' O Hauler Q Indoor <br /> O O Inactive ® Truck <br /> Longitude — O Planned Q OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice of Violation O Extension <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 m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days i (Required for NOV or EXT) <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 i O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Other: § <br /> CommentsRU J7 ' 1 <br /> aftic\I i7G <br /> Inspection Form Included: ,� f <br /> Comments Included: 7,7 <br /> uslness Rep's ignature Phone Number Insp c rs Ognaffijre Phone Number. <br /> INSTRUCTIONS ON BACK �;� Correct: Incorrect E,' AjM F �. 3 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />