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=orR Waste Tire S"e & Inspection Re o"Inspection Report Number <br /> State of California <br /> M <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I1 - 1140925 <br /> Callfomia Integrated Waste Management Board <br /> Part A-Survey BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- � Inspection Type (Fill one) <br /> Site Suffix: l (� C( `p 1 O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sac) r, Cb1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �1j <br /> -S d- Q-) ? Inspected By 1 Inspector <br /> t 1' <br /> Physical Address <br /> Inspection Date 1 0 3 l <br /> Sk i n CA �5-.os 1 <br /> Time In Time Out <br /> Business Rep Q� Title 1 O AM V O AM <br /> "Xn n ONA Ora• _ PM V +PM <br /> S CRSOperational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> - Active Q Passenger • Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - I Q Planned 'OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) l <br /> Q New Tire Dealer O 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 0 Other (@,��I �1SS . 0I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A-1 HAULING AND MANIFEST REQUIREMENTS <br /> �i 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other:§ <br /> Comments (Ina <br /> •� _ <br /> N ���n5 O S aS�,r�,s Cc�r�ces n• - <br /> Inspection Form Included: QI <br /> Comments Included: e -- -- —` b <br /> - Bu ines gsS iig n ure _ Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK LCorrect:0 Incorrect: X A�' �/ EX A Joh P � 112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L © ■ <br />