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�. Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 - 114 0 5 6 2 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_ -BLUE-OR-BLACK INK PEN__ <br /> Business Profile Inspection Details <br /> TPID- Inspection� � r, � - 4 � Inspection Type (Fill one) <br /> �Site Suffix: 1 "` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: q 1 CHP CIWMB Complaint Educational Visit Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> Physical Address <br /> C�a vine. °1 O c���n; c. 3 - I O I <br /> E'Ar, <br /> p6 <br /> Inspection Date � � � l a <br /> J Time In Time Out <br /> BusinessRepTitle 3 I AM 0 AM <br /> 1 lyI V PM O _0 PM <br /> (� i1 Qu r�l�tr U wnd' -- -- - - - <br /> -- --- --- — -- ---- - Operational Status Tire Type Business Role Storage Type <br /> ' I ' <br /> Tire Count(Whole/PTE) C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger •Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> 0 O Inactive ®Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 16 Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> 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 <br /> m / m <br /> O do 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ - <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included: J <br /> Comments Included: � <br /> Busin sLr s Rep s Signature Phone Number Inspec 's Signature hone Number <br /> ^ � 62081 <br /> INSTRUCTIONS ON BACK Correct * incorrect: (:�,{�� � Pir E;�f � � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />