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_ Waste Tire Su. ray & Inspection Report Inspection Report Number <br /> -➢772''.7 State of California i <br /> ■ <br /> CIWMB181(New 04/04) Survey Form - Page 1 7 1V V V /� Ly <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: 1 J Z T - v i ® Routine Q Re-inspection Q Referral Q Observation <br /> Local s If Referral,choose referral type(Fill one) <br /> Identifier: a,r\ ��G�L7, I � �J,t,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - Inspected By Inspector <br /> Physical Address - l DF�� ��.�t �J�_� <br /> Inspection Date v �j � l � � C� <br /> �'k <br /> Jvv(rt�r�� Time In ` Time Out <br /> Business Rep Title ® AM e AM <br /> Q PM \ I V O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> p <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 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 # 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 <br /> --- - 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 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments () V u,�l�c�l., •�,�-.����_ �C�'��c/�(.c.G �l S � `VAC,- u� `��`U`-^� - <br /> r <br /> X`I <br /> Phone <br /> o�ne`I <br /> N5u-mmberInspection Form ncluded: O on? <br /> Comments Incuded: Q a�� <br /> Business Reps Signature <br /> jlns2or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V X A Nth <br /> ® White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />