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■ Waste Tire Su► .ay & Inspection Report Inspection Report Number ■ <br /> State of California <br /> C!WMB <br /> 181(New 04/04) <br /> Il - 1143582 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J � Inspection Type (Fill one) <br /> Site Suffix: I �? `I V '5 tJ Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> L� ` � - If Referral,choose referral type(Fill one) <br /> Identifier: J 0 CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> t--� <br /> Physical�A dress' l �I <br /> �7 ( Inspection Date /r*'l 4•j C) ` C) <br /> � � A q�1 o Time In (, Time Out <br /> Business Rep TitleI f AM 0 AM <br /> -- <br /> -- - - - --- - - -- -- - -- -- - -- 0 PM <br /> Operational Status Tire Type Business Role f Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) i (Fill all that apply) <br /> 0 Active 0 Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - 0 Planned Q OTR 0 End-Use If Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader 0 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 ® Hauler 0 Agriculture Q Shredder 0 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 /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> Q 0 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 DCT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 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 a In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: - - - Wr—,gntre_ <br /> ® p's Signature Phone Number n Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect X 11 P,' c <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />