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Waste Tire Su. . Ay & Inspection Report inspection Report Number 0 <br /> State of California I 1 - 1143553 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey - -- ----- <br /> Business Profile Inspection Details <br /> TPID- � � � ' ` � � 4 Inspection Type (Fill one) <br /> Site Suffix: ` L•� I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: S(�� J�1��1� Cru Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I,�� <br /> Physical Address <br /> a��� �1uvv� �s • <br /> Inspection Date s O , <br /> Time In Time Out <br /> Business Rep Title � O AM O AM <br /> •G O 9 PM lJ a PM <br /> _ <br /> -1' n )Ul C es - e' C. Operational Status Tire TypeBusiness Role Storage Type <br /> L <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � <br /> Active ® Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ! Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / FrI <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 /> 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 f 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments � <br /> �cu69 1�0P a � �� 1r� X11 � <br /> Inspection Form Included: Q <br /> Comments Included: 1111, - <br /> 1 ` Iaa-ww vwwv <br /> Business Reps ignature Phone Number Inspe is Signature hone Number <br /> - — - - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect I + 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y: <br />