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ii- <br /> AWaste Tire y & Inspection RepdWnspection Report NumberState of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 11 - 1140723 <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: 1 ZJ 2 I © 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I <br /> �G9G, t f Referral,choose referral type(Fill one) <br /> Identifier: �j`CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Z f <br /> Physical Address 3 q - o <br /> Inspection Date b $ C) Q <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> I / - 4 V 0 PM ® PM <br /> Af <br /> -- --- --- -- - - - -- ----- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � -,- <br /> ® Active ® Passenger ®Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® 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 /> I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [_ENFORCEMENT STATUS <br /> VA HAULING <br /> Q PRC§4295AN1D MANIFEST aste leRr R(egistRrat^oEandS Transport of Tires - - <br /> � ' I,Q Notice Of Violation Q Extension <br /> QQ PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q § 9 Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q j 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 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 <br /> D its C7y1S _ ( �1YCc-�S D�CG�C-V VLA . <br /> Inspection Form Included: Q'i <br /> Comments Included: <br /> Q Busine A's Signde Phone Numbe—}r spector's Signal e Phone Number <br /> { AFI El 1112131 <br /> 62081 <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect <br /> •_. <br /> ■ Cop,-/, <br /> ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />