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LL:S <br /> Waste Tire Survey & Inspection Repoli c Inspection Report Number <br /> State of California I 1 - 1143694 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> A-- _Survey_ _ BLUE OR BLACK INK PEN <br /> --- ------ <br /> ness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l �j ( 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: � L��J�YI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cj- v�kyI PGO l , � <br /> Physical Address V l (J l }�l j k?(m 6j 1 , <br /> CA �aGS - <br /> Inspection Date / � / �'✓ � / <br /> �tV It <br /> Time In Time Out <br /> Business Rep Title `AM I&AM <br /> 0 vZ G OPM C � OPM <br /> - --- -- - - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger 40 Generator I�� Q Outdoor <br /> O • Closed Q Altered I <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned r♦ OTR Q End-Use Q Container <br /> siness 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 /> U 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 j A HAULING AND MANIFEST REQUIREMENTS 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 <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 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 /> 00 <br /> 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 /> QQ Other: § <br /> Comments Svt�}S2�1 i1l5DP �7TJY1 ( v)I 6-r�- ? Car mc fiz�� oy��c,5 <br /> 'a 0 Imc K, 6j"ZJIN <br /> 15-1,66 <br /> Inspection Form Included: Q d <br /> Comments Included: - — <br /> Q ---- <br /> Business Rep's Signature Phone Number I ct Signature Phone Number_ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V! 1 XjkMLPjL1E1 111213 <br /> ■ -- - -- ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />