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■ ' Waste Tire .,urvey & Inspection Re[,-rt Inspection Report Number t <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I1 - 1140979 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> mess Profile Inspection Details <br /> AD- r inspection Type (Fill one) <br /> J <br /> Site Suffix: 3 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local \^ If Referral,choose referral type(Fill one) <br /> Identifier: ` � ( .L v\r ` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Lvc t'l l 1 o AJC)Irl Y-,j l'l 0 <br /> Physical Address <br /> l n Uo <br /> -- Inspection Date o2- / O 6 � i o <br /> G1 EC)C/ Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' G ® PM I J `OPM <br /> Operational Status Tire Type Business Role IStorag <br /> e Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ,tf- <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> 0 ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use 1 ® Container <br /> Business Type (Fill all that apply) ------- <br /> New <br /> _New Tire Dealer Q Auto Repair 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 Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> 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 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 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 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> pection Form Included: Q �. ) <br /> Comments Included: Q .rty-1veCi TU _ rGl 6V-_ -L,0&f -- --- — 9-QA—'5-,!l iZ4r!7—�— <br /> Business Reps Sig- ture Phone Number Inspe t r s n ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK CorrectV Incorrect 7s' P� Z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■, <br />