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ttl. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California I 1 - 1144021 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> A-Survey _ - _ BLUE OR BLACK INK PEN <br /> - - - - -- - - <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` ' t,/ •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCkA ' vlV� CCS Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ Inspected By Inspector <br /> 5, leer scic"phcJ Gzr)erct t <br /> Physical Address '3 �j _ l �C <br /> l <br /> rA3 6l I t�cq-*\ l*ctc:'�eCC_A_U <br /> Inspection Date / / j 1 <br /> k,(>,►m PC 01-1 Q 6 c tC/ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' - ® PM S / 0 PM <br /> - --- 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude 0 ® Closed Q Altered IV/11 A'�_4 <br /> GPS /�ja Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> •siness Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreadef Q Dismantler Q Tire Derived Fuel <br /> U 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 / /4 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility , ENFORCEMENT STATUS <br /> VI A HAULING AND MANIFEST REQUIREMENTS <br /> I Q Notice Of Violation Q Extension <br /> Q Q <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 / <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m m <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 /> Q 014 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 I 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 G�NlC�U � �VL 'K� A n, C — <br /> .3.nS�•ec,I-i 1�fi\. r3 [ a � c� ��,I:Lr •fizvt� c'n' �' ��ncCi r►.� <br /> _�St� c_Zc�V-I SS ._i`z aVI A0 - <br /> t <br /> Inspection Form �nc <br /> ncluded: Q n <br /> I Comments luded: -- - -- - - - — ACI?— <br /> `-Yf' jG 73 <br /> Q Business Rep's Signature Phone Number Signature Phone Number <br /> - -_ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: i NI/ �£ P( � 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />