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SIR--� Waste Tire S;A ey & Inspection Repo Inspection Report Number' ■ <br /> �o^ <br /> State of California � `\ . <br /> CIWMB181(New04/04) Survey Form - Page 1 I` 1 r2 - 10' 1 0 7 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile :inspection Details <br /> TPID k—L Inspection Type (Fill one)Site Suffix: C) Routine 0 Re-inspection 0 Referral 0 Observation <br /> .l <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: &L' 0 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other 1 <br /> Business or Facility Name MAr�J t 5 C0 P, //V Inspected By — Inspector <br /> I A+ra Tl(,jr, G — �t11(tG\e , I _ _j— <br /> Physical Address // DI 1 . 1�m,y- <br /> 00 E, Voc( nL' BJP- — -- ---- <br /> Street �l <br /> Inspection Date <br /> I C(PL T r Ct <br /> City State- ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> t— I p f m MOPM m m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( > ❑f �LL_�DDQActive . q) Passenger (a Generator (R) Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude m . 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude – 0 Planned O�OTR �0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 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 Other IA)f (I /Q, (' t( Vi { <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 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 0 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days -- (Required for NOV or EXT) <br /> 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 I 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> 3 G 11t 6V Pr + <br /> Qw F c J (rt (c Oil <br /> inspection Form Included: <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct- Incorrect: ( E .A E 1, 2 3 62081 <br /> ll t ,� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />