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Inspection Report Number <br /> Waste Tire Survey & Inspection Repo. <br /> "a ' S ateCIWMB <br /> f 81(New <br /> Survey Form - Page 1 <br /> CIWMB 181(New 04104) Y 9 1 1 1088327 <br /> California Integrated Waste Management Board J <br /> -t A-Survey BLUE OR BLACK INK PEN <br /> — - - -- - <br /> iness Profile Inspection Details <br /> PID- y Inspection Type (Fill one) <br /> Site Suffix: l C.) Jr P 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r �\ If Referral,choose referral type(Fill one) <br /> Identifier: ` 'L`/l ,� ���`�1 � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> Name ► Inspected By Inspector <br /> Physical Address C� ` 1�I� A"r,rA <br /> l L- 3 60k_n)C,'1'1 <br /> (� Inspection Date 5 1 1 <br /> C-� Time In lJ Time Out <br /> Business Rep Title / ] _, <br /> 0 AM 0 AM <br /> ri v1�'L'Y1 MC/l k,.1 l ! 3 O PM ` a ® PM <br /> Cam n te- rl,*6ke)) Cwti, I,ztive rt6 , <br /> 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 Q Generator Q Outdoor <br /> ® <br /> O Closed Q Altered 1')1A AOA <br /> GPS Latitude Irl1 N Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <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 ® OtherL � '� 0t� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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 (Required for NOV or EXT) <br /> Q Q 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 /> mer2 - - -- <br /> Wspection Form Included: Q A"\ <br /> Comments Included: <br /> Business Rep's Signature Pe <br /> Phone Number s c r' gnature Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ( q I XJA M L 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />