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■ tie- Ins ection Report Number <br /> WasteState of California <br /> teTire Survey & Inspection Report p p � <br /> i CIWMB 181(New 04/04) Survey Form - Page 1 Il - 1140551 <br /> Management Board <br /> California Integrated Waste Manage <br /> P-4 A-Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> TPID- ' � � � � � � - � � Inspection ffiType (Fill oneP Q Referral Q <br /> Site Suffix: Routine QRe-inspection Observation <br /> Local �— .- �A If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I l <br /> Physical�ddr qss �C�1� 0 <br /> IoL�C� U) Qf cc�- <br /> -Tj ac� A Inspection Date ' 1 I 5 , 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM (� 0 AM <br /> O #1 PM 3 V ® PM <br /> (Fill one only) (Fill Type <br /> apply) Business Role Storage Type <br /> Operational Status Tire T e <br /> ^ (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) J� <br /> Q Active Passenger Generator ® Outdoor <br /> O 1* Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O <br /> Q Inactive Q Truck � <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 /> .J Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®OtherSl � <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 NOV or EXT) <br /> 0 014 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 I 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 /> eV <br /> 6f wo-us u[ Itnown. <br /> spection Form Included: Q l <br /> Comments Included: ®I - -- - �v <br /> usiness Rep's S, ,,atWre Pflone Number Inspect 's Signature __ hone Number J <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X WEI 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />