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e Tire Su e & Inspection ReArt -inspection Report Number <br /> � •; ,� Wast y p - <br /> State of California J1 1127461 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> PartA- Survey - -- - - -- - - -- .- - - - <br /> -- ---- Inspection Details <br /> Business Profile _ - -- <br /> TPID- h _ Inspection Type (Fill one) <br /> Site Suffix: V 3 3 $ y ® f Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(� �(�(,(, (� �f1Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �uA, G <br /> Physical Address <br /> (� Inspection Date <br /> �(�,������ "� Time In Time Out <br /> Business Rep Title � l , ( � 5 �PM 4 ® " PM <br /> -1 101\ 1 . — "� - - -- - <br /> __ x�d-,rte,p�k D r - - - - <br /> 1�� �� d v,� Operational <br /> one only) <br /> Status.11 Tire Type apply)I Business <br /> that apply) Storage Type <br /> — p (Fill all that apply) <br /> ( Y) <br /> Tire Count(Whole/PTE) � , <br /> Active ® Passenger � Generator Outdoor <br /> Closed Q Altered <br /> GPS LatitudeQ Hauler Q Indoor <br /> cl Q InacA, Q Truck <br /> Longitude — Q Plalwned Q OTR Q 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 Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 q HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q <br /> Q Q 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 /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 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 In Compliance - No Violations <br /> Q Q 1 Other: § J <br /> Com mentsn,_,_\ `n ns,�-(„1�- f`(�0A D� ��f�I_ Vu�tJ ILC/ C� <br /> 05- C,LfQS—� <br /> _PR__ <br /> Inspection Form Included: Q <br /> Comments Included: Q J <br /> Business Rep's Signature Phone Number Insp tor's Signature 66qj�v <br /> Number <br /> -- — --- - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ; �"kC <br /> Z 2 3 <br /> � - - - -- © ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator <br />