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Waste Tire Survey & Inspection Report Inspection Report Number <br /> StalMB1181California <br /> Survey Form - Page 1 1 1 1 0 2 5 6 3 2 <br /> =MB 1181(Now 04104) � <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ O _ / O Ins ectlon Type (Fill one) <br /> Site Sux: <br /> ffiout"" + Re-inspection Q Referral Q Observation <br /> Local if <br /> Referral,chooso referral type(Fill one) <br /> Identifier: t l ,To(,(� �u(1 C6(A'l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> /� Inspected By Inspector <br /> �ptv> LMdro <br /> i1 OOkkd,' JDtelr� a,-1lfteyi.�?Physical tJ <br /> ' �Obi JAI�cls( (�-.,u.s .�►� <br /> Inspection Date <br /> �!'el�Lcl C4 q. �3 <br /> Time In Time Out <br /> Business Repitle� � �/� 0 AM � Q AM <br /> RI,C*C Ti1 ru-fe 1�, '�(RGC fikt'�'t`'CG• O PM 0 PM <br /> Operational Status ii Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> / ®Active (9 Passenger ®Generator @ Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck + <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 4) Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility �ENFORCEMENT STATUS <br /> V? A HAULING AND MANIFEST REQUIREMENTSNotice of Violation <br /> Q O .PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 10 Q Extenlott <br /> O ; Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Dead)lne ' <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O , O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements ' Date I <br /> O ! O i 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O ;14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requued farNQtfor <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Rttte'red t clva11[(gA� t <br /> O ! O 114 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 InWrl�1 ` Y19 <br /> O O __. —.�. �. u <br /> Other: § s.. s-.,s'�. <br /> Comments e'✓is��U C( �� { SQtl�flGtLj(uvl �OuZ tit- wwks W01 piek U_P <br /> vtlast-� lirt s �1,c� le-ave- makL, eS+s �D oect�vtect�f t irrz �w�t.(s �f ��c1 <br /> op- more, La-&d .4%t>fo Me-citaitic 4-6al- waste- 7l'iAg-5 reMOVQJ <br /> - from fit,s si-k mash- bQ rxaj-�,5fej, AjarLSe.S7L5 re takQ ©"Nle- Ar 3 ��►-s <br /> -Inspection Form Included: Q <br /> �cor�' <br /> Comments Included: Q <br /> *Ict*,r' n�tureB0nZRp Signature Phone Number <br /> Phone Number <br /> .. <br /> INSTRUCTIONS ON BACK correctV Incorrect: (* LJE1 1112 3 62081 <br /> ■ Entered White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />