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® Waste Tire Survey & Inspection Report. Inspection Report Number ■ <br /> tai State California 11 - 1140605 <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> ` BLUE OR BLACK INK PEN <br /> A- Survey <br /> iness Profile Inspection Details <br /> i r-ID- c Inspection Type (Fill one) <br /> Site Suffix: 1 7 O I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: <br /> scto J l7� urn C(7u��" 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - - - - — <br /> Business or Facility Name 0-.) ], Inspected By Inspector <br /> � D U, Cb��"� � I,t,C.�iti n � � _ lot �C <br /> Physical Address &nW <br /> (A In 5aM Inspection Date 10 <br /> b L Time In Time Out <br /> Business Rep Title 9 AM 0 AM <br /> 0 PM 1 v O PM <br /> __No, - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor j <br /> D 40 Closed 0 Alte�e{i � !/V <br /> GPS Latitude IkVN4A 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> Business Type (Fill all that apply) _ <br /> Jew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> _ Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> ZL <br /> -- -------- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A j HAULING AND MANIFEST REQUIREMENTS j <br /> 10 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 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 <br /> (Required for NOV or EXT) <br /> 0 0 <br /> 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/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: § L_ <br /> Comments ��n <br /> 111-�_GI. <br /> _pection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspe or's Signature RHone Number <br /> — --- _— - <br /> INSTRUCTIONS ON BACK [Correct* Incorrect ; � � ?� A � p LE g 2 � 62081 <br /> - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />