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Waste Tire S y & Inspection Rep�'�Inspection Report Number ■ <br />71i State of California <br />CIWMB 181 (New 04/04)Survey Form -Page 1 I 1 - 1127689 <br />California Integrated Waste Management Board <br />?art A - Survey .._ _-_ _ BLUE -OR -BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -/� Inspection Type (Fill one) <br />Site Suffix: ` y O 6 o l ® Routine Q Re -inspection Q Referral Q Observation <br />LocalC �� , 1 ` re If Referral, choose referral type (Fill one) <br />Identifier: J �y 60 1 / 0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />, VA ' 0� to Y161 Mu� P� i � C� j <br />Physical Address — (Dl [ �rn LUjet <br />`��� � �✓ Inspection Date 1 � 1 1 � 1 /✓1 <br />V Time In 1 Time Out l LJ <br />Business Rep Title <br />-YC.7iY'G'���I_----�VIUJ�IYIGtVI <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />O <br />Longitude <br />Business Type (Fill all that apply) <br />F O PM l Q PM <br />Operational Status <br />Tire Type <br />Business Role <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />0 Generator <br />Q Closed <br />Q Altered <br />O Hauler <br />0 Agriculture <br />Q Shredder <br />Q Hauler <br />Q Inactive <br />Q Truck <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q Planned <br />Q OTR <br />O End -Use <br />Q New Tire Dealer <br />Q Auto Repair <br />Q Trucking Fleet <br />® Government <br />Q Retreader <br />O Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />Q Collection <br />Q Crumb Rubber <br />O Service Station <br />O Hauler <br />0 Agriculture <br />Q Shredder <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />t) <br />n <br />Other: § <br />Comments <br />Storage Type <br />(Fill all that apply) <br />® Outdoor <br />O Indoor <br />Q Container <br />Dismantler O Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />® In Compliance - No Violations <br />Inspection Form Included: <br />Comments Included: Q <br />Bu In s ep Ignature Phone Number c r' Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: I* Incorrect: \� A 12 3 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink opy: ® ■ <br />