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® Waste Tire SL.. vey & Inspection Repo - ` Inspection Report Number ■ <br /> L.7 <br /> «� State of California 11 - 1143532 <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- t-� / Inspection Type (Fill one) <br /> Site Suffix: i 5 3 Q L( - 0 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I ,nIf Referral,choose referral type(Fill one) <br /> Identifier: VCL,n Y L )��Uvl (E)(,A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business oorFacility Name Inspected By Inspector <br /> Physical Address rJ� A lK <br /> „r+_ Inspection Date 7 L?( <br /> C`F Time In Time Out `J <br /> Business Rep Title O AM f� O AM <br /> ' ® PM j ' ePM <br /> cr Iw kA- -u back d6A. - --- - �. <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 Q Passenger--le Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® 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 ®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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> � Imen --- --- - <br /> _1NZ <br /> Inspection Form Included: O �Y *C. <br /> Comments Included: VBCorre <br /> — �- tea`=-�— <br /> gnature Phone Number e _ Phone Number <br /> INSTRUCTIONS Oct: Incorrect. (Lfj �� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator ® ■ <br />