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Inspection Repor# Number <br /> Waste Tire SY & Inspection Repor ■ <br /> State of California i <br /> CIWMB 181(New 04/04) Survey Form - Page 1 t I <br /> California Integrated Waste Management Board - 0 z 9 <br /> Part A- Survey BLUE OR BLACK INK PEN` <br /> Business Profile Inspection Details <br /> TPID- Inspection� Inspection Type (Fill one) <br /> site Suffix: <br /> � U] ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: L4 S Qr) TOG U In Gout' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p Y Inspector <br /> Physical Address ✓ _ — L31-9j <br /> NJ <br /> Q 1 <br /> — <br /> Street P <br /> ' Ins ection Date <br /> .Mate ZIPCo <br /> Ci(y Time In _ Time Out <br /> r <br /> Business Rep Title O A 0 AM <br /> M <br /> ` ` Tyr C 111 c10' � ' O PM ] O PM <br /> L. �..i. Operational Status Tire Type Business Role Storage Type;, <br /> (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply)t <br /> 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Y- . E Q Hauler Q Indoor <br /> rQInactive Q Truck <br /> 'TTo <br /> Longitude Q Planned Q OTR <br /> - Q End-Use Q Container <br /> Business Type (Fill all that appiY) <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 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 (1) In Compliance - No Violations <br /> Q Q Other: § <br /> Comments (Ia' e till-U-LI I-1 r. <br /> t�-� <br /> -F� A Care <br /> Inspection Form Included: Q <br /> Comments Included.,Q _ _ - _. •. <br /> Business Rep's Signature Phane Number I ectar s StgnatureJ,. Phone Number x <br /> —-- - --— �� - <br /> ��' 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />