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Ispection Report Number <br /> Waste Tire Sure, vy & Inspection Report <br /> *e" State of California <br /> CIWMB181(New04/04) Survey Form - Page 1 I1 - 1140674 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C, Inspection Type (Fill one) <br /> Site Suffix: Z l S 3 0 1& Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Zuy� c, ✓'t Cc9w — O CHP O CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 3 lD <br /> Inspection Date <br /> CA l <br /> Time In Time Out <br /> Business Rep Title l AM Q AM <br /> ® <br /> ® PM C3 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ® Active ® Passenger Generator ® Outdoor <br /> o O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o O Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility P-ENFORCEMENT STATUS <br /> V A , HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Extension <br /> — ...........-- A -- __ _E.. _...___. _._ - <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 /> 0 Other: § <br /> Comments <br /> — - Ur1 S�7IC C -�Cr�7xlrt- "� S C�! s f(o w�y5 <br /> Wag (Ar3ject <br /> Inspection Form Included: � C -- <br /> Comments Included: ®' - - CZE) y6�ro623 <br /> Business Rep's Signature on r spectoes Signature Phone Number ' <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X ( XTAS p (- 1112131 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />