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r i <br /> €.8: inspection Report Number,Tire S & Inspection Rep <br /> ■ 61i: State <br /> CIWM i81(New Survey Form - Page 1. r I 1 - 10 7 3 4 1 7 <br /> CIWMB 181(New 04104) - <br /> Califorfa.lntegrated 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 S Suffix: f �� Q Routine Q Re-inspection O Referral Q Observation <br /> If Referral,choose referral tape(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint. Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> t' 7t a �J v"l fl�� !' ��• 7/A •.t r^C i _ r' <br /> Physical Address _ O ' r �j LJ ( I J�� r? ` �!�,r <c, <br /> Street <br /> Inspection Date <br /> rA � a�0 V <br /> Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title EEI • m Q AM m m Q AM <br /> QPM QPM <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 (a) Passenger Q Generator , Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> O O Inactive (a Truck <br /> Longitude — O Planned Q OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> � Notice Of Violation Q Extension <br /> O O i <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459:1 -Tire Program ID Number from CIWMB <br /> 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q O Other,:§ <br /> Comments l ,t ? / ✓i v t .`lam <br /> R'El',�� 1r �l�"r<l�l,jr �� I/'.r rU�,,., ;�t�" ��4't /l../ <br /> a✓C' � <br /> i '�{�i.l ��Cf�,i/ 1 �, �1�f / L•t( t. �' r �✓'_,�,. � 1V7 j"C <br /> Ic <br /> Inspection Form Included: 0 - <br /> Comments Included 1 Business Rep's Signature Phone Number I ,-- <br /> ns ector's Si nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: YX <br /> X/ UI E .A ffMI L I El I 112 3 <br /> White - to - - - ■ <br /> ■ Copy:CIWMB / Yellow Copy:Operator Pink Copy:LEA ' <br /> t <br />