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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> =811 State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1143651 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey - - - - —-- -- - <br /> Business Profile Inspection Details <br /> -- — <br /> TPID- i /l Inspection Type (Fill one) <br /> Site Suffix: 1 O V I Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: co tt1l r\ ��{'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> MkjXr 6c0AJ3es <br /> Physical Address <br /> S,oC_J�k V f 11 Inspection Date 1 0 <br /> Time In Time Out <br /> Business Rep TitleAM <br /> Q AM <br /> PM J (a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f '—lJ <br /> 11 Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler if Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — Q Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair S Trucking Fleet Q Government Q Retreader Q Dismantler Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler 0 Agriculture Q Shredder O 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 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q I0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ - <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A In Compliance - No Violations <br /> O Q Other: § <br /> Comments AS.)V)Z 71i of-N <br /> okm AAJ A-S,.--Y)OW <br /> �o <br /> Inspection Form Included: <br /> Comments Included: ®I' '', 1PNumber <br /> u ss R Ignature Phone Number Inspec gnat re Phone <br /> -- -- —� 62081 <br /> INSTRUCTIONS 0 ACK Correct: Incorrect: X �;• , I A M 1273 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: E ® ■ <br />