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Waste Tire Suit. y & Inspection Report ispection Report Number <br /> State of fornia <br /> CWMB181'(New 04/04) Survey Form - Page 1 I1 - 1140552 <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 c.�/ / Inspection Type (Fill one) <br /> Site Suffix: ! 1 3 3 D l//v y o / * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` 1 If Referral,choose referral type(Fill one) <br /> Identifier: a'n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name .� <br /> Inspected By Inspector <br /> 901`7 s /1,CJ0 3 cf _ <br /> Physical Address <br /> .2575 3 3 /U <br /> Inspection Date <br /> 5;zoo <br /> Time In Time Out <br /> Business Rep Title OZ O AM a O AM <br /> ® PM 8PM <br /> — <br /> aleOperational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) �j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 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 •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 AHAULING 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 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 /> 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 In Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> Inspection Form Included: <br /> p <br /> Comments Included: ----- � — - —- <br /> Business Re Signat Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect s2os1 <br /> x � p � t <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: E ® 0 <br />