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... ......... <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> eoa State of California <br /> CIWMB 181(New 04tO4) Survey Form - Page 1 1143523 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L4 q o Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local A If Referral,choose referral type(Fill one) <br /> Identifier: C'A '/� cc vl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 39 l C) I A` "C' <br /> eT . Inspection Date -7 3 0 <br /> CA 532 Time In Time Out <br /> Business Rep Title0 <br /> I : 1 9 OAM 0 AM <br /> PM 40 PM <br /> 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 /> 0 Active ® Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> C) 0 inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 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-1 A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 M / m <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/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 Win Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> d: 6 <br /> Inspection Form Include <br /> 73 <br /> ' <br /> Commmments Included: <br /> ness ep" Signature Phone umber n tor'slig atUre PhoneNumber <br /> 62081 <br /> I a 131 <br /> i Correct: Incorrect: X P i P <br /> INSTRUCTIONS ON BACK I I I <br /> White Copy:CIWMB Yellow Copy:operator Pink Copy:LEA <br />