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Waste Tire Aly & Inspection Rep^nspection Report Number <br /> ■ v�Eti Stateof California <br /> CIWMB 181(New04/04) Survey Form - Page 1 T 1 - 1143726 <br /> California Integrated Waste Management Board <br /> 'art A- Survey - - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection f r/1 � � � � - O ( Inspection Type (Fill one) <br /> Site Suffix: l '` ll Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S Q n J Q �it (n (oAni� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N)a4 11 n Fix rr<1S 3 0 <br /> Physical Address 1 �en ESCOfl <br /> Inspection Date � � V <br /> V I CJl �� ��3 Time In �r Time Out <br /> Business Rep TitleC 0 AM 0 AM <br /> I <br /> l L • J 0 0 P � � � 0 P <br /> - - - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � � {� � <br /> 0 Active Passenger Is Generator ID Outdoor <br /> O Q Closed �Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck 1 <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 Q 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 4b Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 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 /> Q Q Other: § <br /> Comments ` � ,�, t n_ � � 1 -�,� I <br /> Gt V1 A <br /> Inspection Form �nc <br /> ncluded: <br /> Comments luded: �, I <br /> sines <br /> *nalre Phon> mlnspec is Signature -Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �+ �/I ` ), J�4'P I (_I EI It 1 2 1 3 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />