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r <br /> e R <br /> Waste Tire L ,rvey & Inspection Reps _ c Inspection Report Number ■ <br /> StaMB18te of lifornia Surve Form - Page 1 <br /> CIWMB 181(New 04/04) V I 1 - 1140678 <br /> r + California Integrated Waste Management Board + � <br /> A- Survey BLUE OR BLACK INK PEN <br /> - <br /> ness Profile Inspection Details <br /> iD- Inspection Type (Fill one) <br /> Site Suffix: , �j I , �j L/ l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local a If Referral,choose referral type(Fill one) <br /> Identifier: &01 4��L V�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> E)tf�tz <br /> Physical AddressYtx� �� <br /> aco89�lar hn Z-v�e✓ �,l�r.� ��v�. - - -- ---- <br /> Inspection DateCA <br /> Time In Time Out <br /> Business Rep Title ] //�� 0 AM 0 AM <br /> V ®PM �2_ ® PM <br /> --- ------ - - -- - -- Operational Statin Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> n/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "C/J� <br /> Q Active Q Passenger ® Generator Q Outdoor /� <br /> D ® Closed Q Altered /�/A <br /> GPS Latitude A1?A Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Vew 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 n <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other CL-4-4MVn I <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 Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> 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 ' <br /> (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/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 /> ,jection Form Included: Qi cy <br /> Comments Included: *i - WO'(-411,6' 6-73: <br /> Business Rep's Signature Phone Number 41 �s Phone Number <br /> INSTRUCTIONS ON BACKCorrect.* Incorrect _ X A p 13 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />