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Waste Tire Su. ,ey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 I1 - 1127898 <br /> PartA- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l 3 Oc)_ - Q 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1n �exow-x &X'r , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ / Inspected By Inspector <br /> Physical Address '0 Q <br /> Inspection Date <br /> Time In l Time Out <br /> Business Rep Title 0 AM 0 AM <br /> / <br /> l 1 O ' L3 3 0 P I O 1* PM <br /> e I Chay"f � �s 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) 5 <br /> ® <br /> ®Active ® Passenger ®Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR G End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Is Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q 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 ® 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 /> ® G 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / mm / mtl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q G 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 G 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q G 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q G 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q 1 Q Other: § _ <br /> Comments <br /> Inspection Form ncluded: <br /> �Comments Incuded: /usli�ne4�� s <br /> naturePhone Number n t s ig ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X E XJA MlPf L.JEJ 111213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />