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-.111Waste Tire Proy & Inspection RepCoOnspection Report Number <br /> State of California <br /> Board 11 - 1127932 <br /> CIWMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business Profile Inspection Details {{ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r i� rr /f <br /> L � � � � V -1— ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `_ If Referral,choose referral type(Fill one) <br /> Identifier: Cl✓� �C�(J �i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> / I I <br /> Physical Address ( 1.�� ( At 6so k1'c�6-) <br /> Inspection Date <br /> Time In Time Outl ll <br /> Business Rep Title ] AM l /`� O AM <br /> P I o QPM I t V ® PM <br /> _— ( - <br /> ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) T <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 4D New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> all Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station (a Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility E F CEMENT 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 /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days — -- - _- <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <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 IS In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> I <br /> Inspection Form Included: Ia (Z..y)(, S r <br /> Comments Included: ® /�:e <br /> - ( !> 41�spcs Rep's Signature Phone Number S gna re Phone Number. <br /> — -- - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �% � XV hlt t Z-13 <br /> - <br /> -- - -- - - © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />