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■ = Waste Tire Survey & Inspection Repot Inspection Report Number ■ <br /> Bt1il State of California I 1 - 1140598 <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 /> ness Profile Inspection Details <br /> i r-ID- 1Inspection Type (Fill one) <br /> Site Suffix: e " 1 Is Routine Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: Oct � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> --- - - <br /> Business or Facility Name <br /> Inspected By Inspector <br /> � <br /> Physical Address 3- <br /> - 0 1 - -- <br /> Inspection Date � � � � 1 � I <br /> U ) Time In Time Out <br /> Business Rep Title U0 AM <br /> ' 1 OPM 3 S 0 AM <br /> ® PM <br /> l� oscn� nu__ ��05 �`(��n er -- — - <br /> Operational Status Tire Type BinesRole torage y <br /> (Fill one only) (Fill all that apply) (Fill all that apply) SType <br /> uss <br /> (Fill all that apply) <br /> Tire Count(Whole/PTE) � � Jam/( <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Closed Q Altered NJA NIA <br /> GPS Latitude tj Ip Q Hauler Q Indoor <br /> O Q Inactive Q Truck +i <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> iQ Service Station Q Hauler Q Agriculture Q Shredder ® Other coC��[71L�DJ1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q I 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 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 EXT) <br /> Q 014 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 /> § Y q I <br /> t <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 10 In Compliance - No Violations <br /> Q Q Other: § - -- <br /> Comments -11 4c. j ) f7 OJ' <br /> cvxr�A +VC- �0\\Dw %A�__01) <br /> i-0ection Form Included: QI <br /> M /�Comments Included: ---- u l e� '11 <br /> I <br /> Business_Rep's Signature Phone Number Inspecto ' Signature_- Plione Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X E x A P j T m 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />