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Waste Tire Sup .ay & Inspection Report Inspection Report Number ■ <br /> StateMof California I 1 - 1141002 <br /> CIWB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> -t A- Survey_ __—_-- -_ _ BLUE OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> .PID- Inspection i Type (Fill one) - - - <br /> Site Suffix: 1 5 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localt Cru r>� If Referral,choose referral type(Fill one) <br /> Identifier: anlQ�U,)fl - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I Inspected By Inspector <br /> SQ. Iu k <br /> Physical Address <br /> ��gb� w • Sow�es R,a_ <br /> �� G Inspection Date <br /> P J Time In Time Out <br /> lll <br /> Business Rep Title0 AM n O AM <br /> t. <br /> V1 qq SQ 1�t r� <w", --0 ® PM d, �- O- ® PM <br /> -- J— -- - - -- - -- ---- 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 /> f 0 Active 0 Passenger 0 Generator • Outdoor <br /> O ® Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> - --- <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> J Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 10 1 <br /> Q 1 Other: § _,,.t <br /> Comments 1 <br /> n,,w4UJ'l'(TAM C\A)Mc, All. <br /> --�Co�lo--��-n���S n oke '• -- - --- - -- -- - - -- <br /> - 1 V p U <br /> I <br /> _pection Form Included: 0 .1 (�4rhone <br /> CT <br /> Comments Included: ® -- 1 ' CLl1(' _ __ - -- - - -- ------ - -- <1tAyUJ- �Business Rep's Signature Phone Number Inspe is Signature Number <br /> -- -- _ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect ViFE <br /> { ,t,� +j � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />