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Waste Tire SueA Inspection Repor wction Report Number <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1088034 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Pro hspection Details <br /> I TPID- I L4767 <br /> Q - o inspection Type (Fill one) <br /> Site Suffix: O 0 Routine 0 Re-inspection 0 Referral ® Observation <br /> LocalS ^ If Referral,choose referral type(Fill one) <br /> Identifier: an S.aa 9U i n COu' r'' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> _lerrck ChLernlCal Co . ' 3 `1 - C <br /> Physical Address <br /> Kris+i an LuCQ3 � <br /> 1 1010 Mn(3 <br /> Street <br /> Inspection Date <br /> I Stockton GA g5Z0 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> I IOPM m • � 0 P <br /> - J Operational Status Tire Type Business Role r Storage Type <br /> Tire Count (Whole/PTE) { (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I I 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck I NA <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that app <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 A I 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 <br /> M / 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 0 In Compliance - No Violations <br /> 0 0 Other: § I <br /> Comments �r11�1G1 l.rs ]QVC _ Lr Oxp,td- -thIS d&e t7thi Tollnwip3_wQS not <br /> 0 <br /> 1 ta5�e. wed tires s�or oh-SI�� _ All - �- e etvtce .iser olf __ <br /> b Sc i wab Mre Gen er o rnan&v -'rsvci labte <br /> P <br /> Qn-sce . LGrr tamm k- +� -5� r I Go <br /> Inspection Form Included: 0 + i� <br /> Comments Included: l� .:.. _ - - L��11�_vj ) <br /> Business Rep's Signature Ph a Numb��17eZors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Ak P L E 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />