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t <br /> Waste Tire S,, vey & Inspection Repo. _ Inspection Report Number ■ <br /> Ili State of California 11 - 1143717 <br /> CIWMB 181(New 04/04) <br /> - Page 1 <br /> California Integrated Waste Management Board Survey Form <br /> r `A- Survey _ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: C l is Routine Q Re inspection Q Referral Q Observation <br /> LocalCot If Referral,choose referral type(Fill one) <br /> Identifier: _V\ �����f^�.J� C-Ot , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name li l Inspected By Inspector <br /> Physical Address <br /> Inspection Date C f ) 1 <br /> Time In (!} Time Out <br /> Business Rep Title O AM O AM <br /> ' L J b ® PM J_ J ® 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 !, ®Generator Outdoor <br /> - _— - _-- --0 ® Closed ®Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> qew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> v Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ® Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - - - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 i DateJ m / m <br /> Q O 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 /> 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 is In Compliance - No Violations <br /> Q Q (Other: § <br /> Comments <br /> - -- <br /> U <br /> spection Form Included: Q pp , <br /> Comments Included: ® VC r_ �°Jf rLV1k_ 'f=.�GY - --*AAkrP <br /> _vz 1"q 15.-ale - <br /> Business R 's Signature Phone Number ature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect I e 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />