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;?_8FWaste Tire & Inspection Rep(,. , spection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I1 1140828 <br /> California Integrated Waste Management Board <br /> Part --Survey BLUE OR BLACK INK PEN <br /> Buslin ss Profile Inspection Details <br /> TPID- ` � � � � � Inspection Type (Fill one) � <br /> Site Suffix: V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` / If Referral,choose referral type(Fill one) <br /> Identifier: Jee6t n� -M►'1, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ` Ci 1h. <br /> 1 I f "� <br /> Inspection Date l Z, / -s 10 <br /> CA i'kii,2o6- Time In Time Out <br /> Business Rep Title l 9 AM O AM <br /> 4 0 PM ` 1 GPM <br /> — - ---- -- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> O ® Closed Q Altered /16 / <br /> GPS Latitude /11A Q Hauler Q Indoor` <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 Other �-�- ✓i �9�y� >v2 � <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS j 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 14 § . . -Submittalof p Logs within 90 days (Required for NOV or EXT) <br /> Q CCR 1845921 f Comprehensive TriLoi - <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Other: § LLL_ <br /> Comments <br /> Cosi ccr 1G r frr.Q_ a 10i - — - - <br /> �b [� � . r°,�cc.cy,-n r>ti en c) C 4 ,,c_ -7�'' #- IS-0 <br /> Inspe ion Form Included: Q <br /> mments Included: Q — -- - ---- �^_ -- <br /> Business Rep's Signature Phone Number 1540 ignatur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect fr X .fl F L P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />