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..1 Waste Tire Su. Jy & Inspection Report Inspection Report Number ■ <br /> 1- State of California <br /> 4la <br /> California <br /> � ; CIWMBIntegrated Waste Management Board 181(New04/04) Survey Form - Page 1 1 7 - 10 0 6 + 80 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIW%1B 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address C7 <br /> ri-o 1Co'` KAP f o�d�J1.V� <br /> 2-vJ�U� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep ` ,�, 1 Title O AM 0 AM <br /> V'� Q.\l�Wr� PM PM <br /> (� p r'artional Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill afie only) Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 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 /> 10 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 ® 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 41 In Compliance - No Violations <br /> 0 0 Other: § 1 1 <br /> Comments Tc,-All �1 p, ( c�C.S <br /> �oo� essX 4L �- $66 - 8f6-DGor> . �u�►� is w-� sr�e/ <br /> Inspection Form Included: 0 4 && ' C� <br /> Comments Included: 0 -s ��` <br /> B iness Rep's Signature P one NumbPr/� nspector's ignatu_re_ Phone Number <br /> �— -- <br /> X A 1�'I �_ 1 .? 62081 <br /> INSTRUCTIONS ON BACK Correct: Incor ct: r <br /> I <br /> ® While Copy:CIWMB Yellow Copy:Operator Pini C>„ LEA <br />