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Waste Tire Sui .,ay & Inspection Report _ispection Report Number <br /> L �= State of California I - 1127451- <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE ORBLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t-� /(� Inspection Type (Fill one) <br /> Site suffix: 3 l 0 V ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S>afl J0(4, k � f� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1�— <br /> Inspected By Inspector <br /> p <br /> - o4o 0�\ i C(4cs Pf ses LLL - G— <br /> Physical Address s� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title AMC) AM <br /> QPM O 0P <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) <br /> ® Active Q Passenger $ Generator ® Outdoor <br /> O Q Closed Qu Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <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 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 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 O 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 EX7) <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 O 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 1 S ' <br /> Inspection Form Included: Q <br /> ed: Q <br /> iness Rep's Signature Phone Number <br /> Comments IncludInspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS 0 BACKCorrect: Incorrect: (�,} X A 1 2 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Co y: A ® ■ <br />