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Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> Stateof California I 1 - 114 4. 012 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A-Survey — --- — - — <br /> .iness Profile - - - — Inspection Details — <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �� l 1 ID Routine Q Re-inspection Q Referral Q Observation <br /> Local /'� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1f/ Inspected By Inspector <br /> Physical Address l ` C) I l j m 6iJ`6�_ <br /> �. Inspection Date �'1 1 <br /> Time In Time Out <br /> Business Rep Title AM <br /> , l ® AM <br /> O PM 1 l O 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 Closed QAltered A/ N <br /> 14 <br /> PSLatitude Nl Q Hauler Q Indoor <br /> GO Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> -'.tsiness 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 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q - <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 �n �61 k I ) <br /> 1 !V bl c _ 1� �4 1 L , j'3 ✓ 9 v <br /> wri►-6`bn'1 Awe o v\__0- e_, 10A�MG <br /> i vlon ks- �'�? <br /> Inspection Form Included: Q _ rtX- !_.-_...- <br /> Comments Included: Q - - -- - IBusiness Rep's Signature Phone Number Cto �itu,� Phone Number <br /> — —_- <br /> ---- - -- -- -- -- _., 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: 1 ` A <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ■ <br />