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=_ Waste Tire Suty & Inspection Repori' Inspection Report Number <br /> State eez <br /> ee CIWM f 181(New <br /> Survey Form - Page 1 I Z - 0 l 9 3 $ <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� tJ � Inspection Type (Fill one) <br /> Site Suffix: I' Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �C�/t_ �1,911te"-;1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address J C? - yj40V,4 <br /> 'Vq.g 7 Wej� Lit <br /> Inspection Date r d O © 9 <br /> Time In Time Out <br /> Business Rep Title / / * AM / Q AM <br /> O PM � • PM <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 /> ® Active ® Passenger S Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> QOS <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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility : ENFORCEMENT STATUS <br /> -- ---- - - -- -- <br /> HAULING AND MANIFEST REQUIREMENTS r <br /> ' V REMENTS 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O ------- --- — ---- - - - <br /> 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 O 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 /> O Q Other: § -- <br /> Comments - -- -4-6 t,t i- �n 'T`�+f — a r 00, <br /> -740 <br /> r^ v_ <br /> i <br /> Inspection Form Included: Q 04— <br /> Comments Included: Q - (/ <br /> Busin ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Etx A aMy p 1 L I E 111 2 3 62081 <br /> White"1WYellow Copy:Operator Pink Copy:LEA <br />