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Waste Tire Survey & Inspection Repor Inspection Report Number ■ <br /> State of California I �, 1140927 <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- tInspection Type (Fill one) <br /> Site Suffix: 1 Q I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �'•� If Referral,choose referral type(Fill one) <br /> Identifier: �' {� J oe m:,fl W..i,�lQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 5�_Mh �Su�s0()rW1Un <br /> Physical Address <br /> 1\ <br /> ( C� 43S„^ Inspection Date 1 Z I O <br /> t�S�P Time In Time Out <br /> Business Rep Title b O PM ' O V O PM <br /> SQN C,- - - - --- - - �- - - 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 /> � � <br /> O ®Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <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 i-ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O 1 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 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 ® in Compliance - No Violations 1 <br /> O O Other: § - <br /> Comments �13t4 <br /> - - - <br /> %Aova - <br /> - s — <br /> Inspection Form Included: 1 <br /> p O _ O I <br /> Comments Included:0 �v o5$-7073 <br /> ss ep's Signature Phone Number I pec is SSig��e hone Number <br /> -Co • � � - -- — 62081 <br /> INSTRUCTIONS O BACK rrect: incorrect: E A 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />