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Waste Tire .... <br /> rvey & Inspection Rep(,,-L Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1143678 <br /> California Integrated Waste Management Board <br /> Pert A-Survey BLUE OR BLACK INK PEN <br /> -- ------_----- - <br /> ness Profile Inspection Details <br /> rID- Inspection Type (Fill one) <br /> Site Suffix: 5 y 1 Q 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr• ,^ If Referral,choose referral type(Fill one) <br /> Identifier: � ' �V�V 1 � / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phiiysical dr J�pn <br /> 54-13 tbeec-Vier <br /> - y� Inspection Date '7 <br /> Time In Time Out <br /> Business Rep Title ' � � 0 AM O AM <br /> O PM PM <br /> -- Opeone only) <br /> Status' TireF II a ghat apply) Bill all that siness olStora(Fill all Type <br /> apply) <br /> Tire Count(Whole/PTE) (Fill ( ppy) ( apply) <br /> Q Active 0 Passenger ®Generator &Outdoor <br /> - - - -0_ 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - ® OTR Q End-Use Q Container <br /> Q Planned <br /> Business 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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 16 Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q I 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 /> M / 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 NO or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 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 <br /> ection Form Included: <br /> Comments Included. ® - 3� L " (p --.. _t�t—L Gam`-s-- <br /> Business_Rep's 5 nature Phone Number T4 <br /> tor' gnature -_ ,Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X �/ -1 EQ �' LIE1 IiT2W 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />