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Waste Tire SL. ✓ey & Inspection Repos Inspection Report Number ■ <br /> State of California 11 - 1140945 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> `_A-- Surv✓� <br /> ness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: JC�1f� �C7C�C�./1Y1 .�1� / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v 1 Inspected By Inspector <br /> �)&'r\y\ (� , 4\eAtX1 kt'AJ'\ - <br /> Physical Address (6 � ' '� � ���� Aram wc. <br /> Inspection Date <br /> f1k_00,,kVV_A CA ctr �1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> n� 0 PM I ® PM <br /> Operational Status Tire Type Business Role Storage Type I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger Generator Q Outdoor <br /> -�---- -_ O ® Closed II Q Altered I <br /> GPS Latitude Q Hauler ,Indoor <br /> O Q Inactive Q Truck <br /> i <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> u Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ® Agriculture Q Shredder Q Other <br /> - - <br /> - _....................... --._..._.._..------___-- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> 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 /> 0 O -- - - - <br /> 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 ® In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> ,Inspection Form Included: Q <br /> Comments Included: ® - - - 04-- =---��-7-q6-.T � <br /> Business Rep's Sign ure Phone Number In e o g ture Phone Number <br /> --- -- - -- - -/ - — .- — <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V ! ? �t 62081 <br /> — -- — <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />