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is = Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California I 1 - 1127886 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> - BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- I,, Inspection Type (Fill one) <br /> Site Suffix: l V t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: so-0 �O�y1�t WU Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name nn 1 Inspected By Inspector <br /> lI <br /> Corwet <br /> Physical Address 31 Esc0b <br /> ! '' C Inspection Date , a L1 ' I <br /> �'v `7 Time In Time Out <br /> Business Rep Title AM O AM <br /> 1 L, 0,,k)S�2-� ' : � O ® PM � Q 5 0 PM <br /> - c,k l_eu-�.__ _O - --- -- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � � <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1*Active Is Passenger 0 Generator IS Outdoor <br /> O Q Closed I Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive � Q Truck <br /> Longitude - Q Planned Q OTR O 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 /> 0SeService Station 0 Hauler Agriculture o Shredder • Other CGfWG51� K,!al� <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V-]--A- I 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O -- -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years � <br /> Q O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § --- — '4 <br /> Comments <br /> 1 <br /> Inspection Form Included: <br /> O�i �uins,se � <br /> Comments Included: / + <br /> � <br /> Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct.4b Incorrect: �} 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />