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Waste Tire Sup ✓ey & Inspection Repor, Inspection Report Number ■ <br /> State of California I 1 - 1144047 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> A- Survey <br /> iess Profile Inspection Details <br /> TPID- g -1ll Inspection Type (Fill one) <br /> Site Suffix: , 4-1l Routine Q Re-inspection Q Referral Q Observation <br /> Local /�- , <br /> ,, If Referral,choose referral type(Fill one) <br /> Identifier: <�V, -)� � 600 l� -4EI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> `F� ✓ Inspection Date <br /> Vc-h Time In Time Out <br /> ll <br /> Business Rep Title O AM ii O AM <br /> ® PM l ®PM <br /> -- -- -- -- ------- <br /> ----------- Operational Status Tire Type Business Role Storage Type <br /> .� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> D &Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> siness Type (Fill all that apply) <br /> qew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> LJ 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 A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q I 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 /> Q Q 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 /> 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 ® In Compliance - No Violations <br /> Q Q I Other: § <br /> Comments (:✓t lyl(� 1 �Cl T/��l �t't�lt/Y✓Y1C�_- 1 :. � /�G CJ) C, <br /> -- <br /> _/_��� �c- <br /> _ V <br /> NO-77-7&- 01 el �n <br /> Inspection Form Included- Q' CC oO <br /> Comments Included: Q <br /> -- - --- <br /> Business Rep's Signature Phone Number I p for nature Phone Number <br /> -- - - — <br /> _. 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X V; 1 X M P L P T 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® 0 <br />