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., <br /> Waste Tire Sur „�� & Inspection Report tspection Report Number <br /> "i State of California I 1 - 1143489 <br /> CIWMB181(New04/04) 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: ( C2 Ll LJ C) [ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: CoA '1 C' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ <br /> Business or Facility Name <br /> 7 L'�/ <br /> e� � Inspected By Inspector <br /> Physic <br /> al�dresss l (� � S9 <br /> — lAt .S� trl i�t17�iU J� <br /> J /q� Inspection Date —7 � h cl <br /> l Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> - ` O PM / ® PM <br /> - ------ -- --- - - --- -- - Operational Status Tire Type Business Role 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 /> Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — ® End-Use ® 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 Q Car Dealer Q Collection Q Crumb Rubber t, <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 /> 10 <br /> Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O i PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q - -_ - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q I Q Other: § <br /> Comments <br /> ,Inspection Form Included: Q <br /> Comments Included: ®I - <br /> s R�pr e Phone Number ti nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Xi � �� �C� 1 ; 2 3 <br /> ■ White — --- -- - - ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy: EA <br />