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iijq Waste Tire Sup Bey & Inspection Report Inspection Report Number ■ <br /> Stateof California I 1 - 1143746 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> - - BLUE OR BLACK INK PEN <br /> t A--Survey <br /> ----- - ---- <br /> ,iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � LL If Referral,choose referral type(Fill one) <br /> Identifier: 5c1t(� lCt�t'1 {"i. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 C1 - I l of rnm�tJIC-� <br /> � � 1 � � J <br /> LIQ GA � 3�� Inspection Date Q <br /> r �J <br /> Time In Time Out <br /> Business Rep Title ,�, Q ® AM O AM <br /> i;,tv�lt7lrvl�r���+� J 0 PM ® PM <br /> �&t't111C' --- <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 ® Closed Q Altered MA IVIA <br /> GPS Latitude 1/1A Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Rusiness 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 /> Q 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 AT r ,s--+r_1`-Fz <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility l 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 O 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 <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 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 /> C _ - <br /> Ins ection Form Included: L' L #XIA <br /> p d: QIICc� l� ` j._O _C1.1G - AZD�`Yao �L07�Comments Include ®i Business Rep's Signat re Phone Number Ir' ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �1l- , <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />