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iEE7 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1143969 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type (Fill one) <br /> Site Suffix: �j I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SGo 7C)CUqt,6n 6AX�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ` l Inspected By Inspector <br /> Physical Address 5 9 I 'gyp &A0 <br /> Inspection Date S M u I b <br /> CA A ����� Time In Time Out <br /> V <br /> Business Rep 1 lA `Cvn L Title 0 AM I S 0 AM <br /> �e0 • PM l J PM <br /> 1'l - <br /> n AAke_ mctA nk,n4n(C_ <br /> --- -- ---- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor/ <br /> Latitude O 0 Closed Q Altered NA N>A <br /> GPS A Q Hauler Q Indoor <br /> O Q Inactive Q Truck N1 <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair S Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [ENFORCEMENT STATUS <br /> V AHAULING 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> Q O <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: § ���q ''11 � Ll1, l I <br /> Comments Q 1'nxf�fl� IP141oC�lULI C/ll)� Qfl-{ � {iS l�L�,`�fVK 4 CIL 40 01 111)1 1 <br /> b�CAo call <br /> Inspection Form Included: Q- - - - (� J4 V--J1�i <br /> Comments Included: QBusiness Reps Signature Phone Number np ors Si9 <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect I X Ei <br /> �i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co <br />