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inspection Report Number <br /> Waste Tire �_.rvey & Inspection Rep(. p p <br /> 'te$ State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I1 - 1140ls(1 <br /> 42 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ - _ _ - BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffix: 5 3 a © © I* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �t/�� C(,X�/L.�-� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address d1 <br /> t)N 66(� rT "4 KJU l <br /> Inspection Date } <br /> Time In Time Out <br /> Business Rep TitleO AM CAM <br /> p IJ <br /> ,f 1 f ® ® O PM ! 1 0 Q PM <br /> - 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 /> 6 0 Active 0 Passenger 4D Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> n <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Jsed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler ® Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [—ENFORCEMENT STATUS <br /> [-V-]—A HAULING AND MANIFEST REQUIREMENTS 0 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 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / rfl / Ffl <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 EXT) <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/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 /> 1010 1 Other: § <br /> Comments <br /> See <br /> L ection Form Included: 0 <br /> Comments Included: ® ------ "� � <br /> _ Business Rep's Signatu a Phone Number I sp is S' ture Phone Number <br /> INSTRUCTIONS ON BACK I C rroC ect:* Incorrect: 3 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />