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' w <br /> ■ Waste Tire Suk .ey & Inspection Report Inspection Report Number <br /> State of California n - "7 n <br /> CIWMB181(New 04/04) Survey Form - Page 1 I 1) 1 4� h /% n <br /> U0 / J J <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: ` j� 7 , 7 fo 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C'rn Dit c t`^ �%^ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected B <br /> P Y Inspector <br /> �^ , <br /> Physical Address 3 — (> `�' <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title �fyr�5 � 0 AM Q A,V <br /> $.C��r� � Z � QPM l� � ® P?.' <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 Passenger Generator <br /> � ® ® 9 ® 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> /,�roxt'qv-lk -� Dffay ��c.t �v.- 5 t <br /> II co �w { t uf�5 �ctu �� © i,L��y( � I �t� <br /> -� Lv vL C A_ <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Bu In Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ` T r 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � %I C X I A I�",� LTE - 1 2`iJ, <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA <br />