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Waste Tire SL- ay & Inspection ReporApinspection Report Number <br /> &63&1 State of California 1 - 1088082 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I <br /> California Integrated Waste Management Board <br /> Part A- Survey___ _ BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- F�q <br /> IInspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: I i n jockr LAI n Cu n�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 I O <br /> Street <br /> Inspection Date V <br /> L7 State ZIP Code I Time In Time Out <br /> Business Rep Title L 0 AM I O AM <br /> 1 Q Q PM L�LJ-J 0 PM <br /> - <br /> 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 /> 1 % Active Q Passenger Q Generator Q Outdoor <br /> I� FF,0 1 Q Closed Q Altered <br /> W <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that app <br /> Q New Tire Dealer Q 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 Q 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 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 Q 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 I (Required for NOV or EXT) <br /> Q Q 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 I 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 rr <br /> -- - 7- ——, --. — — <br /> Inspection Form Included: Q <br /> Comments Included: 0' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / __ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X '' V " -X!A �'i�M1 P 1 1213 1 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.,,fEA <br />