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Waste Tire Su� ly & Inspection Repor� Inspection Report Number <br /> 3821 State of California I 1 1140900 <br /> CIWMB181(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 Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I S S S .Z b 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: yu — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> •--� --�-^ Inspected By Inspector <br /> P u l r c ee- -4-vi c- <br /> Physical y _ <br /> Physical Address <br /> St - - <br /> Inspection Date <br /> A <br /> Time In Time Out <br /> Business Rep Title ` ® AM `L (10 AM <br /> 0 QPM � I 7 U QPM <br /> Ci�d <br /> - - Operational Status Tire Type Business Role 1 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 ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GP$ Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A -PRC HAULING AND MANIFEST <br /> EHaule Registration Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 § 9 P <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> Inspection Form Included: <br /> P O ---- <br /> Comments Included: -LZO y �- <br /> ®i Bus! ss Rep's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X { A JJ4 ALI 11 ! (� 62081 <br /> i"i <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Cop :L ■ <br />