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i <br /> Waste Tire Su*ey & Inspection Repora Inspection ReportNumber <br /> ®0® State of California T 1 ® ^ `t V <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 lX9 <br /> California Integrated Waste Management Board ! <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile — <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / i' _ If Referral,choose referral type(Fill one) <br /> Identifier: ! �.7 Vr r (/t1.o 0Z(Y, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f <br /> V Inspected By Inspector <br /> Physical Address _fC <br /> `l ) fig c o a PC,/ <br /> Street <br /> Inspection Date <br /> L <br /> t State Zip Code, Time In Time Out <br /> Business Rep Title 0 AM 1 r 0 AM <br /> 6� � � �� 0PM �) `-� � ..�. __1 0PM <br /> — _._ <br /> T _ <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O � Q Closed Q Altered <br /> GPS Latitude 1 ] i Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> _ O <br /> Longitude - Q Planned Q OTR <br /> Q End-Use Q 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 /> 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 /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 Q In Compliance - No Violations <br /> Q Q (Other: § -- - <br /> Comments y, ! { <br /> /t e f/� V Lt t 1 Gt d 1 ?, l i{'t l��' ✓ I Gt F t G7 >! f �'[ it..' . <br /> -c rac-f A-'e-[ frcv� -1 � s 1 h `�ht f� f tee. b Co � ryx 1) � ��a <br /> Inspection Form Included: Q <br /> Comments Included: - <br /> O,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ . _ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �i C. , .i A Mi��, L�E i j 1 , t i ^ 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />