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Waste Tire SIRey & Inspection Repo Inspection Report Number ■ <br /> w State of California I 1 - 1086947 <br /> ;4a CIWMB 181(New 04/04) <br /> Survey Form - Page 1 1 <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 5 JljiJD-_111 <br /> 1 J Q Routine Q Re-inspection Q Referral Q Observation <br /> Locale ^ \ i If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Facility Name <br /> Business or Inspected By Inspector <br /> I y <br /> Physical Address F1 L] <br /> Street f <br /> Inspection Date I IT <br /> In Time Out <br /> Cr�Fv State ZIFCo�_; Time.,.....G1_1,,T-_ <br /> Business RepTitle O AM ` O AM <br /> 1� j I U pp ,� OPM A I . �. OPM <br /> I ol li\ Operational Status' Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> - <br /> Latitude O Q Closed Q Altered <br /> GPS I I . <br /> J Q Hauler Q Indoor <br /> � Q Inactive Q Truck <br /> Longitude Q Planned Q OTR <br /> g _ ! I Q End-Use Q Container <br /> Lon <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 HAULING AND MANIFEST REQUIREMENTS 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 7 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 Wjste 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 Q In Compliance - No Violations <br /> 0 0 Other: § - - <br /> Comments h `, <br /> l <br /> Inspection Form Included: Q, <br /> Comments included: 0: <br /> Business Rep's Signature Phone Number Inspector's Signature _ Phone Number <br /> X � � :� +� �'{{162081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: V �j 11,1213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />