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_ . Waste Tire Sul vey & Inspection ReporT- Inspection Report Number ■ <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 2 - 10 7 94 31 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 6 1 Q � � � _ � fj inspection Type (Fill one) <br /> Site Suffix: 1 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local -3 <br /> If Referral,choose referral type(Fill one) <br /> Identifier: SO,11 3Oa-1 W ��1^� Q CHP Q CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Nam, n Inspected By Inspector <br /> Physical Address �tn ESQ W <br /> \Lk auk <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM 0 AM <br /> o • PM I V PM <br /> I- <br /> ----- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger I$Generator ® Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude O Hauler O Indoor <br /> D O Inactive JA Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br /> ---------- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> �V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -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 /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 /> Inspection Form Included: Q �/' • -� ^�J �ry��}�,' '`0�1�2�N�um <br /> Comments Included: (- AAllll��l[[llB inessRep's Signature Phone Number Inspe is Signature ~� ber <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V1 �{ A M� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop : ® . <br />