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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> =l:a State of California I 1 - 1143741 <br /> CIWMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> +.A- Survey - BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> TPID- `, _ <br /> Inspection Type (Fill one) <br /> Site Suffix: t 5 ' ' �j ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ct✓ V) cc),/) , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address �� �] >C� Amm�l, <br /> j a 0 L cx fc J-v 1k v . <br /> Inspection Date 625 1 <br /> 1rC`C'� Time In Time Out <br /> Business Rep Title ) h O AM 11 O AM <br /> ® PM l —1 PM <br /> - - Operational Status Tire Type Business Role r Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)i <br /> Tire Count(Whole/PTE) � � <br /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O ® Closed 0 Altered �l <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair *Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> U Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m I m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) — <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 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 <br /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: <br /> p O _ <br /> Comments Included: _ <br /> ®'Business Rep's Si Phone Number In a tor' gnature Phone Number <br /> � -- —r -- - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect EXAM S L �( t i 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />