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section Report Number <br /> ® <br /> wa <br /> Tire & Inspection Rep ` p , ^^p/�State B California 1 1 ® V l.i <br /> CIWMB 181(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 i :Inspection Details <br /> TPID- r: �.r �/ �> / j Inspection Type (Fill one) <br /> Site Suffix: '21 7 / _.I J h_� ® Routine Q Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP O CIWMB Q Complaint Q Educational Visit O Other <br /> r Business or Facility_Name <br /> Inspected By Inspector <br /> Physical Address ..— <br /> Scree ��_ / <br /> q Inspection Date <br /> DYJ <br /> / t State QIP Cade Time In Time Out S <br /> Business Rep Title ^�0 AM . 0 AM <br /> 0 PM �. ( O PM <br /> - -_ <br /> 1 <br /> - r Operational Status Tire Type Business Role Storage Type <br /> ti <br /> Tire Count(Whole/PTE) 4 C�` (Fill one only) (Fill all that at (Fill all that apply) (Fill-all that apply) <br /> ® Active Passenger ® Generator 0 Outdoor <br /> Latitude C Q Closed 0 Altered <br /> GPS . 0 Hauler Q Indoor <br /> fO Q Inactive 0 Truck <br /> F��Lon Rude � O <br /> Q End-Use Q ContainerQ Planned TR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber JJ� <br /> Q Service Station O Hauler O Agriculture Q Shredder 1Met'" l.�V(l l _k 1 : ( I (J, Ai <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q ! 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q 0 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q li, 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 /> 0 4 CCR§ 84 Manifest Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Q In Compliance No Violations <br /> - <br /> Comments r rli <br /> L f r��;(,i. '(f Y1.Ct " ! €C �(t.l �t.�,� ta,, i <br /> C ? fr <br /> C,>". Lf d J1�t" L c� 1rf'j�r?C"? (�1 �V( 11'I !;l' % Ur, l� <br /> fcja <br /> k' ` � t( i�f F rp r t k � �.� d C.� fir, 1 ✓Cxkecl1:5%iffiffl: i! <br /> I ItkknOtlrl Included " f �yry✓�✓N fr ^ <br /> ' Comments Included. <br /> Blaslness Rep's Signature Phone Number Inspectors Signature Phone Numbs <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: , 62081 <br /> / -_ A M] !y I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />