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�f Waste Tire Siey & Inspection Repo' Inspection Reptert Number ■ <br /> , <br /> t . <br /> [fififi" State ofCalifornia. <br /> fi�fii:; CIWMB181(New04/04) Survey Form - Page 1 Il - 1088292 <br /> California Integrated Waste Management Board <br /> Part A Surveyy 4 BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details' <br /> TPID- ^ , �' _'3 Inspection Type (Fill one) <br /> Site Suffix: L41 "� / 0 Routine Q Re-inspection Q Referral Q Observation . <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: <br /> �c, <br /> -TdY't90 t n C Ut 1 Q CHP . Q CIWMB Q Complaint Q Educational Visit Q Other <br /> FBusiness or.Facility_Name _ <br /> - Inspected B <br /> p y Inspector <br /> I 1E Ck a 6 C I-As`t•o m C. e a 3 1 D v <br /> Physical Address FAY 1 I t 1r1 �.-t l CCtS <br /> Street _ Inspection Date <br /> t- .� <br /> of � 77 <br /> City j State ZIP Code. Time In Time Out <br /> Business Rep A Title. ll r0 AM O AM <br /> 1 0 PM (9 PM <br /> EE <br /> _y <br /> M G ( G 'G CJI If w fN e r I Operational Status Tire Type Business Role Storage Type " <br /> Tire Count(Whole/PTE) U I J I I 7J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 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 Planned Q OTR Q End-Use Q Container <br /> i <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 ® Other - <br /> ---- I Mo-�-ot c�c_1e ..:�-l1c•. � Ke��tlr <br /> Part B-"Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 'HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q,•1'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§1.8459 . Responsible Entities Complying with Manifesting Requirements Date M / m / 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 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 /> i <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. I <br /> Q Q 1 Other: § <br /> Comments <br /> FovtIn¢ Iris�c c�1 c��.__ or mi -iin IL, e ?Q±z, 14aAz,I�o`w11 T1 J, Jas <br /> ncQd �CiC 11l l�lSrr�--- <br /> cac�`��lc� = 71fuSeC� �vre Y��rrc�y_c11 �C,7"L v,n 0,n)�t`e � <br /> 0�J C&I ck!n S ,or ,n (?gsa (-.C)Y)L(, >n O+e a . <br /> Inspection Form Included: Q <br /> Comments'Included Q�1 / "�` L _ L_: j y. - --.. - - _ 2.,li.,�.__ .,•-�.. `'6 ' f7 _ <br /> Business Rep's Signature Phone NumberInsc �s Signature Phone Number <br /> INSTRUCTIONS ON BACK 'Correct:* Incorrect: ] ,� E . M P �.; 62081 <br /> - -- <br /> e White Copy:CIWMB `Yellow Copy:Operator Pink Copy:LEA ■ <br />