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Waste Tire Sui . ay & Inspection Report inspection Report Number ■ <br /> =o;q State of California 11 - 1143575 <br /> - CIWMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - - - - - - - <br /> BLUE OR BLACK INK P <br /> iness Profile Inspection Details <br /> .ID_ 1 1 Q T� Inspection Type (Fill one) <br /> Site Suffix: 1 -1 2 U S 1 1 O 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalSair <br /> l If Referral,choose referral type(Fill one) <br /> Identifier: �� 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ] ` l Inspected By Inspector <br /> �N STO ES v <br /> Physical Address �� <br /> Gly �,5�03 Inspection Date � � 1 q <br /> e) t)v11 Time In Time Out <br /> Business Rep Title 1 I AM0 AM <br /> l 0 PM 1 U 0 PM <br /> - 10 <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 /> �J Q Active Q Passenger a Generator Q Outdoor <br /> O 40 Closed Q Altered NI <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) C��i <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Q Hauler Q Agriculture Q Shredder Other 1' 4J actl���r <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> V-1 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FF / M / M <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O -- - --- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -_-_ <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> O 1 O Other: <br /> {§ <br /> CommentsPA <br /> .pection Form Included: Q� <br /> Comments Included.. <br /> 7 <br /> ,.,_,-, "hone� 3-291 . ao� yL�3M <br /> Busi p' Signature Number Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X l/IN 11 � 2R 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />