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Waste Tore Suoy & Inspection Report`Inspection Report Number <br /> ■ B8'._ State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 I1 , 141226 <br /> California Integrated Waste Management Board -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ? / 6 3 LU Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �oc� U}t` k �f�( -r j [ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> I <br /> Physical Address IL <br /> _ 3 <br /> +C) <br /> Street { <br /> r Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ` <br /> 0 PM _ I � ' i©� Q PM <br /> f� _alp .� <br /> { Y t .M �.._ .... . <br /> ,.. .._ ._tL P�_t._.�"� �►_... �mm_..._.._. Operational Status Tire Type <br /> Business Role Storage Type <br /> �T <br /> (Fill one only) {Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> The Count (WholeC�'T 4 .a I <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed 0 Alterec, <br /> Latitude <br /> CIPS Q Hauler Q Indoor <br /> o Q Inactive Q -i-ruck, <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> 1 <br /> Business Type (Fill all that apply) <br /> Q 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 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 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 1 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 0 In Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature. Phone Number Inspector's Signature .Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: tom, ' f <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />