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Waste Tire .,..rvey & Inspection Repc.. inspection Report Number ■ <br /> State California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> Il 1140974 <br /> California Integrated Waste Management Board <br /> 't A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l 1 , _ l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ``] `� If Referral,choose referral type(Fill one) <br /> Identifier: Sc�a ec ,_Jm 1 /Inly _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((/ <br /> Inspected By Inspector <br /> Physical Address � <br /> Inspection Date ' 1 Q ` 0 <br /> rctLc.' c l ` <br /> Time In Time Out <br /> Business Rep Title 0 AM I ® AM <br /> O PM Z, O PM <br /> ---- -- ----- -- - -- — --- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger • Generator 10 Outdoor <br /> 0 ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - ® OTR Q End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q 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 ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§ - Q Notice Of Violation Q Extension <br /> 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 / m <br /> Q 1 Q i 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 <br /> 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 1 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 Q In Compliance - No Violations <br /> 1010 Other: § <br /> Comments <br /> Inspection FormIncluded: OI <br /> /�-�--ZOICu!lberComments Included: Business Re Signature Phone Number Insp or's nature Phone N <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I I ] 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />