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Inspection Report Number <br /> Waste Tire Suk _ey & Inspection Report <br /> State of California <br /> CIWMB181(New04/04) Survey Form - Page 1 I 1 - 1127470 <br /> California Integrated Waste Management Board <br /> Part A_Survey._ -_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> _ _ — -- - <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: I 3 1 �� D ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /t If Referral,choose referral type(Fill one) <br /> Identifier: �V� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address U <br /> 5151 Pc�_ci fiz Avcv - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title'I ) <br /> 00 <br /> nC.Ir1i�J nIG nn�� I ' O O PM l ' - iX l O PM <br /> -- <br /> ---- -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> PS Latitude 0 Q Closed Q Altered Q Hauler Q Indoor <br /> G <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 /> 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 ® Other corn on t <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 O 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 O 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 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/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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments - <br /> �yhlt�,1' `F <br /> Gr <br /> Inspection Form Included: ?Oqq ',4 5v <br /> Comments Included: Q - -- W--L `>-'[ (� <br /> usines R p' ignature Phone Number - Ins a to s Ignature Phone Number <br /> -1 6208 <br /> INSTRUCTIONS ON BACK � Correct: Incorrect: \z *} v) I � X IV 111213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink op A <br />