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Inspection Report Number <br /> Waste Tire Su . ✓ey & Inspection ReporL ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 11 - 1143848 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey - — - - <br /> Business Profile inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffix: 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local l ) If Referral,choose referral type(Fill one) <br /> Identifier. �7CLv \v� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical AcFdress k1� <br /> l�L L{ - <br /> Inspection Date V 3 <br /> Time In Time Out <br /> Business Rep Title i ii�,' � � O PM � � � ® AM <br /> -•jam ` l.> 1 O PM <br /> �( (i1A(;` �C.t l�Jb�l`� ._ 7� Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 4f Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> --__ - - - <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair 10 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 •Shredder Other (Ckl <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> . -_ _. --- <br /> V A HAULING 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 /> 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 - (Required for NOV or EXT) <br /> 14 -- <br /> 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 I 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 /> 00 Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> �'Business Rep's Signature Phone Number tor' K nature Phone Number <br /> - - -- <br /> I 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :L ® ■ <br />