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0, <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StWM6Callfornla Survey Form - Page 1 11 - �I 0 4 $ 4 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- ( + I _ Inspection Type (Fill one) <br /> Site Suffix: `I 0 Routine C) Re-inspection 0 Referral ®Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. tT ��� 0 CHP 0 CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name "^(jJ) <br /> Inspocted By Inspector <br /> A � L - l o l ,1���w �w <br /> Physical Address <br /> )bio Navl Dr <br /> S h C�-tUI't � � 5 2r�/_ Inspection Date 5 <br /> W Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> ' <br /> R. Card 6 Ne, re� -e_ r)i j QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> f ®Active Passenger Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive (a Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ,.ENFORCEMENT STATUS <br /> ::A -.'I HA LINO AND MANIFEST REQUIREMENT$ Q Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRG§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Dai II <br /> 0 I 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orOC7) <br /> I <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q"jgatel'red(CIWM0 EnforesfMnt <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 <br /> ���tfpQancs �-No Vfolstlons <br /> 0 0 Other: § ,..,:... _--- <br /> Comments Dk_"Ine&S I`s-" Pe jcistr e ash � n <br /> �' �� �V t '� �nw�Gl� �G�c.11A. Fire �iS�OS�ct'4 CcL 14t- <br /> 0 5— 069cG) y00._s i4a5-& f_reS one or tw0 per r4o4h, Arp);-Od rt-J r.0 - <br /> �e ivcd 'TT I ll*� `)-G1,' S vee k . /V o Viol(0-ot—S , <br /> Inspection Form �nc <br /> ncluded: Q� <br /> Comments lud:d: 0 tt/tv t <br /> Business Rep's Signature Phone Number Insp s Sign re Phone Number <br /> INSTRUCTIONS ON BACK A '� O LA �,rP 62oa1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />