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Waste Tire Su. .ey & Inspection Reports Inspection Report Number <br /> ■ -ItR State of California ■ <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1127472 <br /> California Integrated Waste Management Board <br /> Part A-Survey __ _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> F <br /> ID- 1 � �'+' Q � � � - Inspection Type (Fill one) <br /> e Suffix: ` `'I( 0 I ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC ;�,� If Referral,choose referral type(Fill one) <br /> Identifier: �lQ`)� �1 IY ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � 1�� P� �2 rO rbItum L <br /> Phystoa Add�ess ff l Q r 1l t�bU� <br /> 166 it►nn 6 W eS+ - <br /> __ OInspection Date l } 3 q <br /> Time In Time Out <br /> Business Rep Title � � 4-t � o AM � z � PM <br /> �T 0 AM <br /> O PM lJ <br /> -�� - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive a Truck <br /> Longitude - Q Planned Q OTR Q End-Use 1'Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair A 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS �Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 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 / 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 /> I <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § _- - - <br /> Comments 1 <br /> -- ��r,4 <br /> Inspection Form Included: <br /> Comments Included: —WSignature �mess Rep's Phone Number <br /> j� _s a or' S' nature Phone Number <br /> — � `=' (� 62081 <br /> INSTRUCTIONS O BACK rrec Incorrect: *01 <br /> ■ W.6i <br /> Copy:Operator Pink Copy:LEA © ■ <br />