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1 <br /> Waste Tire SL_ r,ay & Inspection Repoomspection Report Number ■ <br /> State of California I 1. 1140680 <br /> CIWMB 181(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: + `� -�l 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local „� If Referral,choose referral type(Fill one) <br /> Identifier: sav\ ( L/ivl 6bG4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 5 � s�►� � - T � <br /> Physical Address Cf <br /> � Inspection Date l � ) 0 <br /> vaCe ilk C�n� c?C QSC- Time In l Time Out l <br /> Business Rep Title O AM 0 ,M <br /> 0 0 ® PM ® PM <br /> ---- ------- ---- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <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 /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PR - 0 Notice Of Violation 0 Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <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 / ITI / 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 <br /> 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 <br /> Inspection Form Included: 0, 7 <br /> Comments Included: ®/(l [( /S �5 <br /> 1 Busines Rep's ignature 7 f`% Phone Number in c or' ignature Phone Ntimber. <br /> INSTRUCTIONS ON BACK Correct:* Incorrect 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ® ■ <br />