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■ == Waste Tire Sur. .-y & Inspection Repo@enspection Report Number ■ <br /> i'" State of California I 1 - 1143706 <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- � C Inspection Type (Fill one) <br /> Site Suffix: J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier_ J� �1n Co���ly Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> a\\�A FOs kk� 3 a - 1 <br /> Physical Addre O I � Gsc0& <br /> 3131 Easy e..M o � Avg_ - � <br /> Inspection Date � � t S <br /> Sho&a 0 q5 5 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> QPM O QPM <br /> - <br /> - ---- -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active Q Passenger ® Generator • Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Longitude - - -Q- Q Inactive Q Truck <br /> Q End-Use ®ContainerQ Planned OTR <br /> �— <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other f O(►L11�� ����CQ, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility .ENFORCEMENT STATUS <br /> V AHAULING 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. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem / m <br /> Q I Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DC7) <br /> 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 /> Q 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Sc- ;c- <br /> _ <br /> Inspection Form Included: `• (J ����lDv-3� <br /> Comments Included: -- - - - - <br /> B iness Rep's Signature Phone Number nsp tor's Signature Phone Number <br /> * I I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect J4ti P 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />