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...................... ....... <br /> _22 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ <br /> a state of California 1127890 <br /> ■ if ClWMB 1181(New 04/04) Survey Form - Page 1 <br /> California integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A.5V_r_Vey_ inspection Details <br /> jBusiness Profile- <br /> inspection Type (Fill one) <br /> TPID 50 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Site Suffix: <br /> If Referral,choose referral type(Fill one) <br /> Local 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: 0 Q,JI&I <br /> — <br /> Business or Facility Name Inspected By Inspector <br /> �, ("� C,- <br /> \<O—r\kI S 0A Serbs 0 ) gen sUn <br /> Physical Address <br /> 2N-0 it r),r Av c- Inspection Date <br /> (A qS,10 U <br /> StoC,\1ko,(\ Title Time In AM Time Out 0 AM <br /> Business Rep OPM 0 PM <br /> Status Tire Type Business Role Storage Type <br /> 000 5V___ Operational St apply) (Fill all that apply) (Fill all that apply)' <br /> (Fill one only) (Fill all that <br /> Business <br /> Role Storage Type <br /> ill all that apply) (Fill a,that apply) <br /> Tire Count(Whole/PTE) I If Active 0 Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> 0 Hauler 0 indoor <br /> GPS Latitude t <br /> G 0 Inactive Truck <br /> Longitude 0 0 PPI,ctive <br /> 0 0 OTR 0 End-Use Container <br /> Planned <br /> ------------- <br /> Business Type (Fill all that apply) a 0 Government 0 Retread r 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet <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 /> Generator, Hauler and End-Use Facility ENFORCEMENT STA <br /> Part B - inspection of Waste Tire Dealer, <br /> V -A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Compliance Deadline <br /> 0 0 <br /> PRC <br /> §42953-Contracts with Registered Waste Tire Haulers. <br /> C <br /> 0 0 PRC 5 42956-Registration/Decal in Vehicle Requirements Datem / m / m <br /> PRC <br /> Cl -Responsible Entities Complying with Manifesting <br /> rog ro 114 CCR§18459 <br /> 0 0 114 CCR 5 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 �14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 0 Referred I CIWMB Enforcement <br /> 0 0 1 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 10 1 0 1 Other: § p L1 <br /> Comments <br /> -------------- <br /> Inspection Form InCIL1111111811111: <br /> Comments Included: Number-er-_ Inspec 's ignature Phone Number <br /> Business Rep's Signature PhoneN <br /> 62081 <br /> 2 3 <br /> INSTRUCTIONS ON BACK �Correct:* Incorrect: <br /> '�' N' a © ■ <br /> ■ White Copy:CIWMB- yellow copy:operator Pink Cop LE <br />