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Waste Tire Sui . y & Inspection Report Ispection Report Number <br /> i[EIZ State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 I1 - 1140876 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK I <br /> Part A_-_Survey NK PEN- <br /> Business Profile Inspection Details <br /> TPID- r Q Inspection Type (Fill one) <br /> Site Suffix: 1 S �p / D 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ty� e�q � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busineess or Facility Name �j Inspected By Inspector <br /> L,,� Ds e-c-kcrva- <br /> Physical Address - 8d' _C:41_ <br /> C) Inspection Date (J [ c-) S j <br /> Lv�e �� y Time In Time Out <br /> Business Rep Title ` 3 Q AM ` AM <br /> 15 <br /> �+ ® PM PM <br /> 41 "" Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) + 5— (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger ® Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 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 /> • Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [ENFORCE_ MENT STA_T_US <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / I / 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!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 0 In Compliance - No Violations <br /> 0 0 Other: § // <br /> Comments G�1� a4Ad III,, do ln <br /> g A 1119kG't <br /> Inspection Form Included: 0' X <br /> Comments Included: ' — _S: <br /> Comments <br /> Rusin s ep's Signature Phone Number Inspector's Signature Phone Number, <br /> / 62081i 1 ' <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: �/AI A 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y: A <br />