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Waste Tire SuNey & Inspection Report inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1141280 <br /> California Integrated Waste Management Board - - --- -- - <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business.ProfileInspection Detaiis <br /> TPID �, ` Inspection Type (Fill one) <br /> Site Suffix � ? <br /> Q Referral Observation <br /> Routine Q Re inspection Q <br /> Tl�___ t.. _..� .__ �! .M' <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. i ' QOM t r\ (O L1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 1 — ! lJ I ) <br /> L <br /> ._ o_ . , <br /> _. . mm..____.. . __ . _ _ _ __.___.__ _____............... <br /> rr'�� 1�] / <br /> q <br /> Inspection Date3 <br /> ? i <br /> : <br /> stat� �,�€.�,�,;�� Time In Time Out <br /> Business Rep Title O AM O AM <br /> t. O PM I �I O PM <br /> _ <br /> -�„: � ;� -� � ;, o.e��, Operational Status Tire Type Business Role Storage Type <br /> Tire oklnt Whole/PTE) (Fill one only) tFili all that apple (Fill all that apply) (Fill all that Wanly) <br /> 'n a Active Q Passenger ' Q Generator Q Outdof?I <br /> [ Q Closed Q Altered <br /> Indoor <br /> Q Hauler Q <br /> GPS Latitude j ` <br /> - Q Inactive Q Truck <br /> Longitude — Q Planned ( 07R Q End Use Q Container <br /> [4 <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 /> . .......... <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 /> PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> UlQ Q , <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m 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 )l <br /> tA <br /> Inspection Form! Inct!.idec°: <br /> Comments Included: 11�3 <br /> Bkssiness Rep's Signature Phone Number Inspf:cta's Sicgnatures Phone Numb:-r <br /> f 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />