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Waste Tire Stay & Inspection Repok Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1143546 <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: O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local v L If Referral,choose referral type(Fill one) <br /> Identifier: ` , ,` v��(� C�;c�1,I�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V I Inspected By Inspector <br /> 1_oc\c, KO-4-- <br /> Physical Address <br /> Inspection Date ,tel l C)��ail C7 Time In Time Out <br /> Business Rep Title O AM O AM <br /> ,n l / ' Q 0 PM ! WPM <br /> �'}'Gt.i'l � �'✓l' tGs I�I�:;,W�"P,v�c�✓ttC f�ecll�,'L� _ - - - --- - - <br /> - - - - ----- -- Operational Status Tire Type Business Role Storage Type <br /> 4+ <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Q Active Q Passenger a Generator ® Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned ® OTR <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 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. <br /> 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 /> f <br /> b <br /> ID N <br /> P <br /> Ti <br /> 1 18459 <br /> C <br /> 14 CR§ . - re Program Number from CIWMB <br /> Q � Q (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 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 <br /> Mf_47 AS <br /> i <br /> Inspection Form Included: Q / G [/ ��in c, <br /> Comments Included: ® /L/� --- 07`� — - �8 <br /> ��'"� - —— <br /> sL iness R s Signature Phone Number p o na re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect e X 62081 <br /> X _ZZZI <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink kill <br /> ® ■ <br />