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.. ....... <br /> r Waste Tire Survey & Inspection Report <br /> Inspection Report Number <br /> ■ = q, State of California 11 - 1144015 <br /> _ <br /> CIWMB 181(New 04/04) Survey Form Page 1 <br /> WCalifornia Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Survey - - --- --- . <br /> ss Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 3 - ® Routine Q Re inspection Q Referral Q Observation <br /> Local ` /, n If Referral,choose referral type(Fill one) <br /> Identifier: ��q1n `J '�, (�;.(,.'/ V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address t r1` Af(;ly,CA q5�0 'Vl�� <br /> Inspection Date '� <br /> Time In Time Out <br /> Business Rep Title j T ®AM 1' --710 AM <br /> 0 PM <br /> t V 0PM ! -- - <br /> _�7 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger ®Generator 45 Outdoor <br /> 0 4P Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> tiiness Type (Fill all that apply) <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O 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 11 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§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 <br /> Q Q Mm / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> i (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q <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 /> 010 Other: § <br /> Comments <br /> Inspection Form Included: f <br /> Comments Included: AAMP <br /> re Phone Number <br /> iness ep's Signature Phone Number _— 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � t <br /> - - -- ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />