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a <br /> Waste Tire : r y & Inspection Rep( tspection Report Number <br /> Si3Y State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1140967 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: if 2 9 9 9 3 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �y�., ye't-AXw O CHP 0 CIWMB 0 Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> C A Inspected By Inspector <br /> Physical Address J (j 3 <br /> I j 3 3 1�c�l� ��k• i <br /> Inspection Date ` (D 1 <br /> G4 I � I <br /> Time In Time Out <br /> Business Rep Title <br /> Q AM ��77 Q AM <br /> L✓� (D 0 © ®PM O 2 G V0 PM <br /> eciclo`1 �sP i n 0 yyU Gt�tLc/ <br /> - - Operational Status The Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ® Active ® Passenger ® Generator ® Outdoor <br /> O Closed ® Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> D 0 Inactive ® Truck <br /> Longitude — Q Planned ® OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet 0-Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer 0 Auto Body O Car Dealer Q Collection 0 Crumb Rubber <br /> O Service Station 0 Hauler Q Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS '' 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 1 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> Q Other: § i`(CLlZ J <br /> Comments <br /> YLO I—ca <br /> !inspectionQI c_ <br /> Form Included: // 1 <br /> Comments Included: ® L'�-- -- ..-_ �.-�'2/tc�t�t �•�O`�/ �{�2� �O(c�L3 <br /> Busin s Rep s Signature Phone Number Inspector's Signa ure Phone Number <br /> � 62081 <br /> INSTRUCTIONS ON ACK Correct: Incorrect: X E -h A' P (, �_S <br /> r-om <br /> am White Copy:CINlMB Yellow Copy Operator Pink C py: <br />