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Waste Tire Sui „ey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) <br /> I 1 - 11410 01 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> 'art A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q _ ) Inspection Type (Fill one) <br /> Site Suffix: �l t • Routine Q Re-inspection Q Referral Q Observation <br /> Local / J, If Referral,choose referral type(Fill one) <br /> Identifier: Sickt) J 0 1k)1) `(� `�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 31 1._Je <br /> x173 Lworn;-� -n F5cotb <br /> U�.J� <br /> �d1 �� �� ��r Inspection Date � D <br /> UI''G.11' 7 Time In Time Out <br /> Business Rep Title O AM Q AM <br /> L O PM Q PM <br /> ccr f(�a�U Seuc,Tc�� --- _ - - - - <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 /> Q Active Q Passenger Q Generator Q Outdoo; <br /> 0 ® Closed Q AlteredAIIA <br /> �q �1 <br /> GPS Latitude Q Hauler/n Q Indoor <br /> 0 Q Inactive Q Truck i <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> i <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 Q Agriculture Q Shredder 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 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 <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/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 /> R.�vl�n,� <br /> Comments 1 �„�_�! /�_t-k. t JI C �. A1rA_46—W1ao�---- �5 r)�� <br /> _ t_n_ nn r�t}L1 a-� <br /> �' II ff 6I <br /> - 5-A) <br /> Inspection Form Included: QI <br /> Comments Included: Q - --- --R_ a�e <br /> Business Rep's Signature �hene Number Insre or's Stynature _ phone Number <br /> - — - <br /> INSTRUCTIONS ON BACK Correct: Incorrect ' 1 E X1 A M1 P I)-1 E1 1112131 62081 <br /> ® White ------- -- ---- - ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />