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--- <br /> 07235050025 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number <br /> »� State of California <br /> CfWMB 181(New 04!041 Survey Form - Page 1 ) 17 - 1 Q $ $ $ <br /> Cafifornla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Businei' ss Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t CJ S j ®RoutineQ Re-inspection Q Referral Q Observation <br /> Localn .�7 � If Referral,choose referral type(Fill one) <br /> Identifier: i. 9t ! �6t= L1To Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility NameInspected By Inspector <br /> (2 4, �j_s :7� <br /> Phys Addressy <br /> Sfre, Inspection Date <br /> tate ZIP Code City =-- - Time In Time Out <br /> City � <br /> Busines �jep y� Title Q AM AM <br /> 1. 0 P l 1 J • QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> y) ( apply) ( ppy) ( apply) <br /> r � (FII one only) Fill all that a I Fill all that apply) Fill all that <br /> Tire Count(Whole/PTE) <br /> f O 0 Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> C7pS Latitude Q Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business 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 /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other. I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A i HAULING AND MANIFEST REQUIREMENTS ®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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days — (Required for NOV or EXT) -- <br /> ® Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _- <br /> ® Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments U_ jCJ�L 5 c��py07Cy a T�f y 1!r 71✓t✓5 ��-rl{9y�.Q <br /> ��''"tNrs'rCi <br /> ,inspection Form Included:Q! /[� <br /> Comments Included: � i !'Zj V 4 l� <br /> Bu ss Rep's Signature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:�)t� V X R M P L E 2 2 3 ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />