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Waste Tire Sur .ay & Inspection Report Inspection Report Number <br /> State of California I 1 - 1143688 <br /> CIWMB181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-- __ BLUE OR BLACK INK PEN <br /> I - -Survey- -- -- _ - -- - _ Inspection Details - - - - - - - -- - <br /> Business Profile __- - - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 5 3 LA 1A r1 5 © I I* Routine O Re-inspection O Referral O Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: S�� ��^ �ure-1�1 O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Busiss or Facility Name ,J� Inspected By Inspector <br /> 0M CkA-)&k (oxnQitYI _ <br /> Physical Address <br /> Cp G6sao Inspection Date �/ 3 Q <br /> Time In Time Out <br /> Business Rep Title O O AM O AM <br /> 3 0 PM O 0 PM <br /> - -- _ -- -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ,rj S <br /> •Active O Passenger 46 Generator Outdoor <br /> - - - - -0 O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned OTR O End-Use l O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder • Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [ENFORCEMENT STATUS <br /> V A 11 HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O ® 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O 0 Other: § l AUP-0 R5'i _ t e S <br /> Comments <br /> Inspection Form Included: O� m� lJ� m � , <br /> Comments Included: �';' � -V w` e �"`^""" <br /> Business Rep's Signature Phone Number Inspe or s Signature_—� _ Phone Number <br /> ----------_ _ � � �'. Jil � p (� � �' 2� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1� �P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />