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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California l 1 - 1143793 <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> -- - - - <br /> Business Profile Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 13 l 3 1 (./ * Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalP. If Referral,choose referral type(Fill one) <br /> Identifier: � -L� j�� I C.� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ((( Inspected By Inspector <br /> Physical ddress /,�, <br /> � G77Lt(iIt I�l✓� Vr. <br /> Inspection Date 1 l/ I 0 <br /> Time In <br /> ►���L�f � Time Out <br /> ( � <br /> Business Rep Title J <br /> ' v 0 PM I@ 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 /> Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR II 0 End-Use ®Container <br /> I� <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair `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 OWer <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 1 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 In Compliance - No Violations <br /> 0 0 Other: § - - <br /> Comments <br /> Inspection Form Included: 01 <br /> — 5/ <br /> Comments Included: Q —- J -- — _ <br /> Busin ep_ i ature Pho a Numbe ignature__- Phone Number <br /> ---- -- --- _-- - — 62081 <br /> [:C:orrect!@1INSTRUCTIONS ON BACKIncorrect: X_ j T <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:LE ® ■ <br />