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' <br /> yy�� teasTire SuO*y & inspection ReportOnspection Report Number <br /> of California j =7 fi - ■ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 a <br /> California Integrated Waste Management Board -. -- - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ) Inspection Type (Fill one) <br /> Site Suffix: ( I —� @ Routine Q Re-inspection 0 Referral Q Observation <br /> ------Local - - --- - - <br /> If Referral,choose referral type(Fill one) <br /> Identifier: ( , J_i I 1 <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By. Inspector <br /> Physical Address —ILI] <br /> Street <br /> ( <br /> EI <br /> Inspection Date �J + IJ <br /> -- = — —-- <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM F �y O AM <br /> 0 PM O PM <br /> J i - Operational Status r Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) 9 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> rro,t <br /> w _ _ <br /> O Active 0 Passenger " Q Generator 0 Outdoor <br /> Latitude ! Q Closed 0 Altered <br /> GPS <br /> E Q Hauler Q Indoor <br /> O Q Inactive 0Truck <br /> Longitude - - -� . ' Q Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Notice Of Violation Q Extension <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O 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 /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § - -- <br /> Comments <br /> Inspection Form Included: Q', <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: J +° a f � 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />