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® Waste Tire Su, itey & Inspection Repor'` Inspection Report Number ■ <br /> State of California I - 1143577 <br /> CIWM13181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> f ' A- Survey BLUE OR BLACK INK PEN <br /> iess Profile Inspection Details - - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l �l 0 t �3 d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local l��c G , If Referral,choose referral type(Fill one) <br /> Identifier: vCl� `'v vL'�� C�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0.S. Eyvt_�-sG r � , A-►��i�Physicall A < <br /> crt- <br /> r Inspection Date <br /> C 4��a1 v <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �-, <br /> r C tJ (W PM V C) O 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) <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> lJ 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 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 (Required for NOV or EXTJ <br /> Q Q 114 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/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 <br /> ®In Compliance - No Violations <br /> 1010 Other: § <br /> Comments <br /> n L <br /> Inspection Form Included: Q <br /> Comments Included: 7�� Win <br /> slness ep S'ignature Phone Number Ins ec r re Phone Number <br /> - - — -- 1 - - <br /> - - — -- -- -- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrectk, I E X1 AMP L I E 1 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />