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® = Waste Tire Su&y & Inspection Report ,Inspection Report Number <br /> .I8 <br /> State of CaliforniaC WMB 181 04/04) <br /> T 1 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 I y 1140715 <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , S Z 2 U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r� l� � V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p y Inspector <br /> ��wrUnc.� A l�t'cr I�-,�c_k;,►�� 3 q - I � <br /> Physical Address v/ <br /> 7 p <br /> Inspection Date .3 / <br /> CA <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O ©Z- • .1;zePM D d C7 QPM <br /> o,,+ c R,cbk�; OCA c.-- 05Y . - -- - - - - - <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 /> J0 Active ® Passenger Generator ® Outdoor <br /> Latitude <br /> Q Closed Q Altered <br /> GPS Q Hauler i Q Indoor <br /> O Q Inactive • Truck i <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 0 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 /> QO 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0=0 Other. § <br /> ' <br /> Comments < i1-A YX-CA— 3 � � TJ"S <br /> `l�•t.t c V�v� ' <br /> - _ <br /> Inspection Form Included: Q �ne%, skignature <br /> GComments Included:® 1`l0 �'�� _ C2 � t �BusPhone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X A,tIV}, Z 2 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Co :L <br />