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=-- Waste Tire Su :y & Inspection Report Inspection Report Number ■ <br /> :'IIiS State of California <br /> -_ CIWMB 181(New 04/04) Survey Form - Page 1 I1 - 1141233 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Dietails <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix: © �] { 3 <br /> i 0 Routine 0 Re-inspection 0 Referral 0 Obseryation <br /> Local ` tt �` If Referral,choose referral type(Fill one) <br /> Identifier: �C („- 1} t C. �`1.Y 1 - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address O / j ` t <br /> \ �1` 1S AyCll/tUL� <br /> Street <br /> Inspection Date I <br /> C, 7 3 <br /> State Zip Code Time In Time Out <br /> Business Rep Title O AM r.. O AM <br /> Ll I <br /> j i 0 P j ' � 0 P <br /> ir <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) j I i <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered, � 0 Hauler 0 Indoor <br /> - 0 Inactive 0 Truck <br /> I-_-- -r--_.. 1._...; F-..... <br /> ....._r_. . _..... O <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 ��tM,F L (� <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 / m <br /> 0 0 114 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/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 <br /> __4 } <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> --- 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X �, eA X Alt i i 1 2 i 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />