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C: C C ) '' ' <br /> FORM NO.M 0A47-CIWMB M12 1607 51e x87654321 <br /> F ee3 Waste Tire Survey & Inspection Report Inspection Report Number <br /> 81➢ State of California I - 1 7 (Aj1 `•/ <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 y <br /> California Integrated Waste Management Board <br /> _ BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 d j I _ 0 Routine Q Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name , V Inspected By Inspector <br /> Physical Addressv.ti. (yt `�`�'�F't'''�• <br /> Inspection Date z <br /> 33 Time In Time Out <br /> Business Rep Title O AM O AM <br /> ® PM 40 PM <br /> !ham }ar r S 6 t�vw1� <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , 1. '00� <br /> ® Active Q Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor, <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 0 Other 01 � tAALL'vA-k f c .- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS - - _— __- <br /> � V j�A Q 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments s ,gz, (�S "p- �N�r.- <br /> R�1N�lV1 P� t fn c!L r fi U` d 7� <br /> , ✓ nyL <br /> 1A/c.. Gia n�4�c�12 rd�ls5..ps_ 12 u`c� a as,7et- /4�' f- <br /> A✓- 'c_uv\ V'P I � S G�IiC 4n0 w.fJi 4I GVL VI CJS t 1n fli �12 C_._ !:yr S_ V' 4141*'NM90� 1AZ <br /> wi, t kc i y 3o fsyc r t Cr4i-f- <br /> o V'16/0 li 0),q <br /> _�Li►s� J � S,- o Q _ rvlu 4r _oY! _S/'f�T - - - _Vi' - <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> IBujinmeh Reps Signature Ph ne Numbernspector�ignat�ure � Phone Number <br /> cnno� <br />