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........... ----- -- ....... <br /> - -------- --- <br /> ---------- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1143971 <br /> COMB 181(New 04104) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey <br /> k,us ness Profile P file Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: So^ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date �5 o <br /> CA qS37-7 Time In 0 AM Time Out 0 AM <br /> Business Rep Title PM C PM <br /> ---------------- <br /> Operational Status Tire Type I 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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered IIIA <br /> GPS Latitude 0 Inactive Truck 0 Hauler 0 Indoor <br /> O <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 container <br /> siness Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 used Tire Dealer 0 Auto Body 0 Car Dealer 0 collection 0 crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> 0 0 �14 CCR§ 18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> 0 0 Other: § <br /> Comments e A,S <br /> -C__;�7 Zan <br /> ct 4)m nq_rn <br /> Inspection Form Included: 0: <br /> age <br /> Comments Included: q Business Rep's Signature Phone Number pi Itur- <br /> Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect:X X A M <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />