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Waste Tirek#e & Inspection Re Inspection Report Number <br /> ■ -6Id State of California Y ■ <br /> CIWMB181(New04/04) Survey Form - Page 1 I1 - 1143670 <br /> California Integrated Waste Management Board <br /> PartA- Survey- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- JJ Inspection Type (Fill one) <br /> Site Suffix: ' ` 0 3 Q 1C l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: �nXcAkkJ� <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> CA <br /> Inspection Date O <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> t O PM O 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 /> 10 Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered IVIA <br /> GPS Latitude � Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 /> i I 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FP / M / <br /> 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 EXT) <br /> Q 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 1 0 1 Other: § 1-841,q —] e.11ea-{,Z. L 1S <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number s ctor gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect i f 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />