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® Waste Tire Su. vey & Inspection Repoi .. Inspection Report Number ■ <br /> bis State B California I 1 - 1144050 <br /> CIWM818,(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> t A-Survey_-- <br /> iness Profile - Inspection Details <br /> PID- Inspection Type (Fill one) <br /> Site Suffix: • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �-� iw\ �t;�/Y1 [�J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name f ` _ _ r Inspected By Inspector <br /> l 6k'Len 1'�YIGC Lo)� to _ 1 <br /> Physical Address lC <br /> Inspection Date 13 <br /> S 1 `vT l CA q��5 Time In Time Out <br /> Business Rep TitleD AM / O AM <br /> O PM / PM <br /> CnA�v �o4\C4,S)IN1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler i 0 Indoor N <br /> O 0 Inactive 0 Truck N!T/n A114 /A <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other /`{'ylf�' t lYlls!tL 7�GVt�1�, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 14 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 /> 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> See-- "n'Tie'a LJ—A� - -- — <br /> ectfon Form Included: 1 �G��GILI�I'���� <br /> r <br /> - ---- -- -- ---- - - <br /> p Oi <br /> Comments Included: 10 <br /> usi ess s SI nature Phone Number a r' Signa uC re Phone Number <br /> INSTRUCTIONS ON BACK CCorrect: Incorrect: ` V) E A l ; ` 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />