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j. Waste Tire Suley & Inspection Reporo Inspection Report Number <br /> ■ T6GOLii State of California `� �} # - <br /> CIWMB181(New04/04) Survey Form - Page 1 I s I <br /> California Integrated Waste Management Board ..,.! <br /> Part A- Survey BLUE ORBLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) } <br /> Site Suffix: ' I I Q Routine Q Re inspection Q Referral Q Observation <br /> C� C1Q lA�(1 Calur}� O CHP Q CIWMB 0 Complaint) Q Educational Visit Q.Other <br /> Local;` If Referral,choose referral type Fill one <br /> Identifier: <br /> Business or Facility Name Inspected By Inspector <br /> I <br /> Physical Addrbss qq MS9 (3 1 J <br /> Street 7RJ_��] / Q U- s / lo:T�P,I <br /> Inspection Date <br /> CityF State ZlP Coda Time In Time Out <br /> Business Rep Title -� O AM O AM <br /> O PM Q PM <br /> Operational Status Tie Type <br /> Business Ro elel Storage Type <br /> FIII one only) FIII all that a I FIII all that apply) (Fill all that apply) <br /> TMeount (Whole/PTE) <br /> ( y) ( pp Y) ( pp y) <br /> 6 ® Active O Passenger Q Generator O Outdoor <br /> Latitude Q Closed O Altered <br /> i GPS �,VT�� ^� � _- � Q Hauler 0 Indoor <br /> O O Inactive O Truck <br /> Longitude – � s Q Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber 1 <br /> O Service Station O Hauler O Agriculture Q Shredder ® Other I C)_ r_ctfk-x1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Q 'PRC§42951 -Waste The Hauler Registration and Transport of Tires 0 Notice Of Violation Q Extension <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / 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 /> 0 Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 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 <br /> iQ� )Q A 7�(Om -)rC_y?Cl' t= <br /> Inspection Form Included: 0 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: XA M <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />