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Waste Tire Survey & Inspection Repo, c Inspection Report Number ■ <br /> =tes <br /> State of California 11 - 1140651 <br /> CIWMB181(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 /> - - - <br /> ,iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 Q Q 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � , �� tt, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> q (— <br /> Physical Address 3 L �, ® � A l'T�'iJQ m iwt, <br /> Inspection Date / O /CA q �1 f a <br /> u� /�� Time In Time Out <br /> Business Rep Title ��II 0 AM 0 AM <br /> V 0 PM • 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 /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> ® Closed 0 Alter_e�1 <br /> AIA <br /> GPS Latitude IBJ t , Q Hauler Q Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Rusiness Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> v q HAULING AND MANIFEST REQUIREMENTS i0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or F_XT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> - - - � ►mr -- - -_ --- - - <br /> P, <br /> Inspection Form Included: Oi <br /> Commen <br /> nsPeCommen s Included: U-L�w -- � c �/`Z16a-Y6 <br /> Business Rep's Signature Phone Number Ins a Ig ure Phone Number j <br /> --- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect IG� �/l 1 3 f� i t <br /> ■ White Copy:CIWMB Yellow Copy:Operator J Pink Copy:LEA ® ■ <br />