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0-31.96..0,40482 <br />en.Waste Tire Sur�y &Inspection Report Inspection Report Number <br />�;�;iL State of California <br />CIWMB 181 (New0QN) Su rve�/ Form - Pa e 1 I 1 11084 9 7 <br />California Integrated Waste Management Board J <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - <br />Site Suffix: <br />` <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />r <br />I- - <br />y <br />5 <br />- ; -' <br />I I f <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />Local <br />` /� L <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />�(l J <br />(�1 C �Civ� �TC�/J <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q CHP Q CIWMB Q Complaint <br />Q Educational Visit Q Other <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Business or Facility Name <br />CO'nC'a1� <br />Q <br />Inspected By Inspector <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />�_ _ <br />Physics dress - - - <br />- i <br />_ <br />` D l <br />LA_ �- ` A111Ah ,' <br />L_a-R6.O � <br />Q`7 <br />I <br />Street <br />Date <br />��Inspection <br />a. <br />City <br />Business Rep <br />State <br />Title <br />z_ Cor'0 <br />T_ime r__ __ <br />/ ; AM <br />Time Out r__ <br />I / I , I 0 AM <br />l I QPM <br />V! O PM <br />j/ I <br />Operational Status <br />Tire Type <br />. Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />t 1 <br />(Fill one on <br />(Fill all that apply) <br />- <br />. (Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />® Generator <br />® Outdoor <br />Latitude <br />GPSQ <br />Hauler <br />Q Indoor <br />Q Inactive <br />(D Truck <br />Longitude - <br />Q Planned <br />® OTR <br />Q End -Use <br />® Container <br />Business Type (Fill all that apply) . <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder Q Other I—__ <br />_i <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I A I HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />® In Compliance - No Violations <br />)10 1 Other: § J I L <br />Comments �Q QV Imo, �G c, ayL _4Aq ` <br />on Form Included: <br />L4 2`5 oy- <br />2�ti 4 Sc� • �; r 91 <br />Comments Included: Ua -!� -- f-� "��✓ <br />{ Busine Re& Signature Phone Number Ins i( <br />INSTRUCTIONS ON BACK Co ect: I orrect:j (� E X A P <br />White Co y: CIWM Yellow Copy: Operator Pink Copy: LEA <br />_`C63 q77__� <br />Phone Number <br />62081 <br />