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032SOOS000I <br /> = Waste Tire Survey & Inspection Report Inspection Report Number <br /> r <br /> State of California <br /> CIWMB 181(New Survey Form - Page 1 . I 1 1127650 <br /> CaliforniaalifIntegrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: . I / I Lola? 10 1- 0 i / <br /> �} O Routine O Re-inspection O Referral O Observation <br /> Local `, I If Referral,choose referral type(Fill one) <br /> Identifier: Duo _j O CHP O CIWMB O Complaint 0 Educational Visit O Other <br /> Business or Facility Name <br /> j'��e,� �,,�,�//W_ <br /> ,•/ / I , �� Inspected By Inspector <br /> Physical AddreWa� <br /> ss <br /> Street -- <br /> /�/� /�� 9s 331 i O Inspection Date i D - I 9 <br /> L____ `-V�-vt-f`-tT- - - -- — - Time In _ Time Out <br /> Cit r stat ZIP Ccde _ <br /> Business Rep Title I ' -1 Q AM f I �3F�j 0 AM <br /> � ���0PM � V ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) L� 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' Active ® Passenger 0 Generator 0 Outdoor <br /> ..i O 0 Closed 0 Altered <br /> GPS Latitude - �� , I O Hauler 0 Indoor <br /> L�__J O Inactive ®Truck <br /> Longitude - I i I _J 1 i O Planned 0 OTR O End-Use ®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 /> Used Tire Dealer Auto Body Car Dealer <br /> O O y 0 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other L /r <br /> L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 'ENF,ORCEMENT�STATU.S; <br /> V,,��ffA�" HAULING�AND MIANIFEST REQUIREMENTS "` <br /> „yl gQ 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 `k <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB v. m / m <br /> + ( �/ or� <br /> 0 O 14 CCR§ 184 59.2.1 -Submittal of Comprehensive Trip Logs within 90 days redYorNOVt <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Refereed 1 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 /> O 1 O Other: § t N . <br /> CommentsFO1� Q <br /> 6--kola raadSI& alqv d(A PKpt —al-e ek P der bvi_i566 f _. SntnK q <br /> y�e� _► sires bo e otos <br /> Inspection Form lncluded: 0 C1"9 <br /> Comments Included: <br /> Bus! s Sign ureii Phone Number Inspect ,g Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre t: I correct: 1EjX RjP L E 1 2 3 <br /> White Copy:C M Yellow Copy:Operator Pink Copy:LEA ® ■ <br />