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Waste Tire Sup vey & Inspection Report , Inspection Report Number <br /> rill State of California Il - 1127697 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-,Survey_____ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q I Inspection Type (Fill one) <br /> LA Suffix: 1 ` 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SOL Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> F \Mk T;ce- q - 1 o <br /> Physical Addressn <br /> Sko c40 r\ CA 9 <br /> 5aO5 Inspection Date <br /> Time In Time Out <br /> Business Rep Title � I 3 5 •AM 0 AM <br /> O PM PM <br /> pp <br /> 3q.roka `J can n 0 n Owne t -- - — -- - -- ---- <br /> — ------ — --- -- - ---- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 Q ('� <br /> 40 Active 49 Passenger 0 Generator 0 Outdoor <br /> O Q Closed � Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck ' <br /> Longitude — End-Use ® Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station • 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 <br /> Q Notice Of Violation Q Extension <br /> Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date / m / m <br /> Q Q <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q <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 In compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> — <br /> Inspection Form Included: <br /> Comments Included: ---- <br /> Busin -Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK i Correct. —Incorrect X' V' X A ,nth P � �� �� � � 62081 <br /> 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />