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.. Waste Tire Su. rey & Inspection Repor, Inspection Report Number <br /> State of California 1 - 1140910 <br /> CIWM6181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Surve _ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 a 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ Inspected By Inspector <br /> Physical Address 3_9 I 41 <br /> Inspection Date15905 <br /> Time In Time Out <br /> Business Rep Title 0 AMAM <br /> l OPM 0 P <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) 9 � <br /> -&-- Q Active Q Passenger Q Generator Q Outdoor <br /> O • Closed Q Altered"� IVI 1�j <br /> PS Latitude Q Hauler Q Indoor <br /> G <br /> O Q Inactive Q Truck /A <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 A <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AA 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 /> 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 <br /> 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 �� s �,�� -��� y ��Ib�c ?A?S C� 1701rc) <br /> S�� �l Itit �Pr L✓t c�Yt�f�t� <br /> o 'er , \ ��- v ► � v � rr� Gti t. sti <br /> e[r7. <br /> Inspection Form Included: Q <br /> Comments Included: Q - — — InBusiness Rep's—gnNumbep o <br /> 's ig ature _Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X JI Xj"A M1 = [31 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Co ® ■ <br />