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t-a Waste Tare Inspection , pill inspection Report Number ■ <br /> State of California 1127733 <br /> CIWMB181(New 04/04) Survey Porn - Page 1 I1 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ -__ - BLUE OR_B_LACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Q � Inspection Type (Fill one) <br /> Site Suffix: l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: U\: l C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . Inspected By Inspector <br /> Physical Addles anC, C,1��e��� � q - <br /> ad5t� <br /> (A)olDQ C) . <br /> Inspection Date <br /> Time In Time Out v <br /> Business Rep ` Title ® AM ` 9 •AM <br /> t1 M \ H ti'IGS Ck\ / O PM l I Q PM <br /> W1vVl OW C - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE). v <br /> S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �' <br /> *Active I® Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 40 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <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 /> V I A HAULING AND MANIFEST REQUIREMENTS i <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <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 /> 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 1 Q 1Other: § <br /> Comments t r � <br /> Inspection Form Included: Q <br /> Comments Included: - <br /> Business Rep's Signat a Phone Number n p to' nature Phone Number <br /> -- - -- <br /> -� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: /! P I O � t 3 6208 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pinkpy' ® ■ <br />