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Waste Tire Sur,.-.y & Inspection Report ;nspectionReport Number <br /> State B California Survey Form - Page 1 <br /> � CIWMB 181(New 04/04) y g I 1 - 1127741 <br /> California Integrated Waste Management Board <br /> Survey BLUE OR BLACK INK PEN <br /> Part A- <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: ` Iy ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: J aA J ock Ui n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 o I ESC�JC <br /> Inspection Date ' a � D r7 <br /> Time In Time Out <br /> Business Rep Title L� O AM O AM <br /> 6 PM A PM <br /> Is lukmko- --- ` 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) <br /> ' to ®Active Q Passenger ®Generator Q Outdoor <br /> WGPS Latitude D O Closed Q Altered 0 Hauler Q Indoor <br /> O Inactive Q Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O 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 �� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.4-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 1 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: § - <br /> Comments <br /> t <br /> rill <br /> Mt kV' C4, ".rf 4 <br /> Inspection Form Included: Qli, q ,,p 5.1f , <br /> W t tYSignatuComments Included: QBusiness Rep's Signature Phone Number re - (j�Ph�one311�G7_ <br /> Number <br /> - - - -- - — -- -'-� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect ? 4 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />