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=rWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> �_� State of California -I 1 1127888 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey _ --- - _ - - - --- il <br /> Business Profile Inspection Details <br /> TPID- U /r� Inspection Type (Fill one) <br /> Site Suffix: 3 ` v ' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� I If Referral,choose referral type(Fill one) <br /> Identifier: d �n L0 NA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other j <br /> Business or Facility Name nl� Inspected By Inspector <br /> Physical Address C(1 <br /> ES <br /> 2,O u 0 -- <br /> L\ Inspection Date <br /> � n ATime In Time Out <br /> Business Rep Title /, AM l d AM <br /> � m QPM l I I O QPM <br /> Cj-, Ilk ---- - - - <br /> I Fill one only) (Fill all that apply) Fill all that apply) Storage Type <br /> Operational Status Tire Type Business Role <br /> ( y) pp y) ( pp y) (Fill all that apply) <br /> Tire Count(Whole/PTE) I G <br /> Active Passenger ®Generator Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive Truck <br /> Longitude – 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS ---._ <br /> 1 HAULING S AND MANIFEST REQUIREMENT <br /> V 1 A I 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § — <br /> n�J <br /> Comments 1�-nj� W '1(�. <br /> Inspection Form Included. 0' - <br /> (�,,�� VInsper"s8- <br /> Comments Included. �I <br /> Business Rep' Signatu� Phone Number e Phone Number62081 <br /> INSTRUCTIONSON BACK Correct:* Incorrect: X White Copy:CIWMB Yellow Copy:Operator © ■ <br />