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. - <br /> MWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> -'Ill State of California I 1 - 1143747 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> _- - BLUE OR BLACK INK PEN <br /> A- Survey <br /> ness Profile Inspection Details <br /> TPID- -� 1 Inspection Type (Fill one) <br /> Site Suffix: 1 J 1 `Routine Q Re-inspection Q Referral Q Observation <br /> Local cIf Referral,choose referral type(Fill one) <br /> Identifier: �C�� l- ��\�� CCrlJ1�1 t v/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l/ !ll Inspected By Inspector <br /> 5&--, <br /> Physical Address 3 1 1 nC� rv� <br /> Inspection Date <br /> LobiTime In Time Out <br /> Business Rep Title 10 AM AM <br /> 1 L] 1 I <br /> Eyl V1YUYlz Vt�,1(e. I ( L 1 O PM 1 l G 7 Q PM <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 /> - O <br /> o Closed Q Altered /1!/A <br /> GPS Latitude /VIA <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - — - Q Planned Q OTR Q End Use Q Container <br /> Misiness Type (Fill all that apply)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 A"rr scck--tt�e- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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 E>M <br /> li <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 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 / <br /> Inspection Form Included: ^ <br /> P QI <br /> o1O �SLk�Z <br /> Comments Included:�! Gl.�@� Yv U N`s`' - - -- -- - _ _ e Nu <br /> _ Business Rep's Signat_r_e Phone Number In e t r' Si nature Phone Number <br /> -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct 40 incorrect: l � X A M P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />