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Waste Tire y & Inspection RepcB*lnspection Report Number ■ <br /> BIt® State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1127734 <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 /> V <br /> Site Suffix: q ,� 0 5—,3 — a 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ,n `\,�. qj If Referral,choose referral type(Fill one) <br /> Identifier: 7l l r t �(�(, f ' 4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> o(j Corr oyzx <br /> Physical Address Aw6k <br /> qS& per[ <br /> a Inspection Date 1 z / Cj <br /> 5J 06 Time In [ Time Out t <br /> Business Rep Title0 AM Z O PM <br /> Q PM <br /> s -1 <br /> I�,�N'►�1'1G,r1 t <br /> Vlwti\ 1l <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 /> 1 .0" 0 Active Q Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude — Q Planned Q OTR 0 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 /> IV A I 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 /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m , m <br /> O Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 Q 1 Other: § <br /> Comments L j� J / <br /> - { I <br /> cry- A-w-et's cA <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> 2CK <br /> ep's Signature Phone Number Ins S natur Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON Correct: Incorrect: X P i 2 <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pink opy:L ® ■ <br />