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Waste Tire Of^ & Inspection Replaospection Report Number <br /> ■ ••`;ii State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1127924 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business Profile I Inspection Details <br /> TPID- / I r� Inspection Type (Fill one) <br /> Site Suffix: 4 vC ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ✓VL �Cx tG�t/1� �n''w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l�ISU A-eccjn kk d1A�_ <br /> /�� Inspection Date <br /> ,/� <br /> l 6L�YLC� "1Jr' �' ! t✓ <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> c� t a � � 00 PM � � � ® PM <br /> �(� <br /> I Operational Status Tire 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 /> -- ®Active Passenger ® Generator I Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Container <br /> Q Planned Q OTR <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 /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS _ <br /> FV I A_HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - Q Notice Of Violation Q Extension <br /> 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / 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 EXT) <br /> 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 Other: § <br /> Comments <br /> el <br /> (Inspection Form Included: Q C i ! <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins e o Si nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co ® ■ <br />