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_:. <br /> Waste Tire Soft & Inspection Repo ` spectionReporttAumber <br /> `-•' State of California <br /> CIWMB 181 New 04/04 { <br /> Californ> Integrated Waste Management Board Survey Form — Page 1 { 0 1 <br /> Part A- Survef� _ BLUE OR BLACK INK PEN <br /> Business Profile ianspection Details <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: I t r ': (���� �0l� Q Routine Q Re-inspection Q Referral ® Observation <br /> Local �— If Referral,choose referral type(Fill one) <br /> Identifier: ouuntil <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> L <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical Address <br /> Street. <br /> Inspection Dated L—ol-81 <br /> Crry State Zip Code Time In Time Out <br /> Business Rep Title T O AM 7 II Q AM <br /> 0 PM <br /> - <br /> aa� Operational Status Tire Type Business Role Storage Type <br /> Ttre COU17t(W ofe(�'1`�) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ! Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered Q Hauler LLIQ Indoor <br /> GPS . � QInactive Q Truck <br /> I o <br /> Longitude 1 , <br /> Use OContainerQ Planned Q OTR End <br /> Business T e- Fil( II that 2 `l71 <br /> �� <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 (9 Other L-.UTYIbCr Pr-0&IC_A.,; <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q O 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 <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 /> Q Q 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 O 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 /> O O Other: § � , <br /> Comments _ <br /> rA rxAt -- -CLL <br /> r� -a`����-�� -� X�n�t-t�*1'i\ �Y_�C�1 -t;;�(�'d?1��=-• ����1 �a r �_��� 1 � <br /> Inspection Form Included: Q - <br /> Comments included: Q - <br /> _ p 9 <br /> Business Rep's Si„q nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X (`�x l A M� ( 62081 <br /> � � 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> ® f White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />