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= Waste Tire 8*06y & Inspection Rep"Inspection Report Number ■ <br /> ■ -."; State of California I 1 - 1127939 <br /> CIWMB 181(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- ` G� �} Inspection Type (Fill one) <br /> Site Suffix: } 7 1 0 a I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ---- If Referral,choose referral type(Fill one) <br /> Identifier: �(,�y� J Qct�{�,(� l (�VL��1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CC13llrul clnr ,�SlQ` [_ <br /> Physical Address is�� <br /> C(1 <br /> 11 <br /> AVC- 1 - <br /> Inspection Date , <br /> La X6337 <br /> I Time In Time Out <br /> Business Rep TitleO AM ( O AM <br /> 1 I 3 O 0 PM 1 ® PM <br /> el�rJ��rscn pafk3 m5(- - __. -- -- -- <br /> -- - - ---- Operational Status Tire Type Business Role Storage Type <br /> t <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I.(1 <br /> ®Active ® Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — End-Use ® Container <br /> O Planned Q OTR <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> I Q Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O 1 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 11 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O ( O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators LIS In Compliance - No Violations <br /> O O 'Other: § S ^, <br /> Comments Ting, (P0.51 <br /> K)o \h j, —a[, (was 4 waw, <br /> Inspection Form Included: Q (y <br /> Comments a.­ <br /> Included:® `-- <br /> Business Rep's Signature Phone Number Inspec is Signa re one Number <br /> --- - - <br /> INSTRUCTIONS ON BACK � Correct:* Incorrect X lE X A JAE1 1112 31 62081 <br /> - - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />