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Waste Tire Sus y & Inspection Report ispection Report Number ■ <br /> State of California 11 - 1140880 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 C, 3 kLl _ 0 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J !/ Inspected By Inspector <br /> All <br /> �r 71lIYLB�Ct uX i. n <br /> Physical Address — l /'13 !/W,441 &IC* 4 C^'� <br /> 0 <br /> Inspection Date 0 L4 ! 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM Q 0 PM r .z > <br /> - <br /> f/ Operational Status Tire Type i Business Role Storage Type <br /> Tire Count(Whole/PTE) y <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � f � � <br /> ®Active 0 Passenger ® Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ® Truck I <br /> Longitude — 0 Planned 0 OTR 0 End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ® 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 /> _ 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ------ 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 /> 00 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 1 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 I& In Compliance - No Violations <br /> 0 0 Other: § — - -- - <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: — <br /> B sines ep s igna a Ph Number Inspector's Signature Phone Number. f <br /> INSTRUCTIONS ON BACK Correct: Incorrect t ;' 'X A 12 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C <br />