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sa�zWasteaTire S e Inspection Repor', <br /> li� Ir Iction Report Number <br /> of <br /> ��� CIWMB 181(New 04/04) Survey Form - Page 1 1 - 10 7 9 4 3 2 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey _ <br /> Inspection Details <br /> Business Profile <br /> TPID- Inspection Type (Fill one) <br /> (l <br /> Site Suffix: Ll 9 5 Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: ,yt ��� -CJl/1�. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or <br /> Facility Name Inspected By Inspector <br /> Physical"VdI ress f*5 �`j — l D i /T t 1` <br /> 1'YZ'a <br /> Inspection Date 1 <br /> CA` Time In ` Time Out <br /> Business Rep Title 40 AM 19) AM <br /> G C) Q PM O PM <br /> 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 (a Indoor <br /> O Q Inactive ®Truck <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 ® 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 ® Other /71C7e_1- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 W / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 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 1 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 /> Inspection Form Included: QI <br /> Comments Included: <br /> moi-yob o2�6 <br /> Busine s Rep's Sig ature Phone Number jq <br /> ture Phone Number <br /> - - —------ -/-- 62081 <br /> INSTRUCTIONS ON BACK [C:orrect:0 Incorrect: i�� N E � � � <br /> ■ ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® <br />