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Waste Tire Survey & Inspection Repo, [ Inspection Report Number <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 I1 - 1140924 <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 U Routine Q Re-inspection Q Referral Q Observation <br /> Local `— If Referral,choose referral type(Fill one) <br /> Identifier: JQ u� Cb Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical dress Ren E 5 <br /> ao), <br /> c�c <br /> C n C��„ Inspection Date Q 3 1 I <br /> IrL` -�1C� <br /> Time In Time Out <br /> Business Rep Title l O AM O AM <br /> • CJ O O PM 0 e PM <br /> Operational Status Tire Type Business Role <br /> (Fill one only) (Fill all that apply) Fill all that apply) SFillll all thatapply) <br /> e I <br /> ---- ------ ---- - ---- <br /> Tire Count(Whole/PTE) ( pp y) ( pp y) <br /> Q Out oor <br /> Q Active Q Passenger Q Generator <br /> 0 Closed Q Alteled NAJIAX <br /> GPS Latitude N Q Hauler Q Indoor <br /> O Q Inactive Q Truck�A <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) -- ---- --New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 01 Q ® In Compliance - No Violations <br /> Q 1 Q Other: § _ <br /> Comments <br /> w --mak - <br /> - <br /> t <br /> --` dlC>>i UIS S� CJ�l2 �_(� 1 5 t <br /> Inspection Form Included: Q t <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number 4insper's Signature hone Number <br /> _�_._......... 6208 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A -I 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py' A <br />