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Waste Tire Sufey & Inspection Repor, Inspection Report Number <br /> iGi=Z State of California — <br /> CIWMB181(New04/04) I 1141314 <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board _____ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t `� L' �� - 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `\ If Referral,choose referral type(Fill one) <br /> Identifier. >1 � (� Ir� -^ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> ' - <br /> P Y Inspector <br /> Phy sica.T; d Cess ' OT <br /> k <br /> �.1 <br /> i <br /> -T-] <br /> SfrQef <br /> aJ5<1?6 <br /> Inspection Date <br /> State Z1P Code Time In Time Out _ <br /> Business Rep Title i t 1 I 0 PM 4- r� PM <br /> _�_ >� s � _ 3 t �Y� t r <br /> 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 /> t '� 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> -' -- • �� - - 0 Inactive 0 Truck <br /> -�... .. --. ._.. 0 <br /> Longitude I 0 End-Use 0 Container <br /> I I <br /> g + i I 0 Planned 0 OTR <br /> Business Type (Fill all that°apAIY) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ,Qtx l� <br /> f► � x37�t i <br /> 7h A2 - , Make) ' <br /> Inspection Form Included: 0 <br /> d <br /> �.. <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X X A, Mtn L;� I �� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />