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=_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> .�= State of California I 1 - 1144022 <br /> C IWM B 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> I A- Survey_ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> I PID- IIInspection Type (Fill one) <br /> Site Suffix: ' S �-� C� Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �(��� JC� �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Cl l c) I m6o /"Tm'Y b_)", <br /> 1-cVC-144- <br /> Inspection Date <br /> CA c15Z3 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> l lJ ® PM LI ® PM <br /> - Operational Status i 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 /> Q Active Q Passenger ® Generator Q Outdoor <br /> O 0 Closed Q Altered -%/14 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive i Truck <br /> Longitude - Q Planned Q OTR ' Q End-Use Q Container <br /> "•gsiness 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 normo �yyl/ri112 &vo2/ _- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ' ENFORCEMENT STATUS <br /> V II HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q QA <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 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 I (Required for NOV or EXT) <br /> 0 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/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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> r <br /> �,.zpection Form Included: Q <br /> Comments Included: C� - — --� , 964 4?91�-73 - J <br /> (—US) ss p s Signature Phone Number Ins or naturePhone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: w! 1 E ?C A Ak p L E I 131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />