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091-6104004:3 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> eee: <br /> �� State of California <br /> r CnwMB 181(New 04104) Survey Form - Page 1i I 1 - .10 8 8 4 8 4 <br /> Callfomla Integrated Waste Management Board I _ <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q► Inspection Type (Fill one) <br /> Site Suffix: LL�� U�—_I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local IC .S-� 1 UVUU If Referral,choose referral type(Fill one) <br /> Identifier: �n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name "1 Inspected By Inspector <br /> IPhcaAscan���� Ser_vrce.__ II - '' �_I `o <br /> L_ <br /> 1 ;In-- <br /> ESco <br /> d ess L _ <br /> Inspection Date <br /> ��' — --_`� � Time In — Time Out <br /> 33 <br /> Cr Sfate Vii, Go:; _ <br /> Business Rep Title i r - -- -- AM T I - <br /> IMAM <br /> O PM --I--J-- O PM <br /> P�o,�do t�o - �►�� -- -- Owner_ -- -- --- - - - J- <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) (Fill all that apply) <br /> t ' Active 0 Passenger 0 Generator, 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> _ O 0 Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR O End-Use 0 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 /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> r 1 <br /> Service Station Hauler Agriculture Shredder Other <br /> Part B -Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility BENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O Notice Of Violation Extension <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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX77 <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 Refe red!C-IWMB Enforcement <br /> O 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 O 1 Other: § <br /> Comments <br /> 1 `t`• J <br /> Inspection Form Included: 0 <br /> Comments Included: -— � � <br /> � uslness R 's S nature Phone Number Ins, oI SSignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK7orre . Incorrect: X A M PIS111,2N3 <br /> WhiteYellow Copy.Operator Pink Copy.LEA <br />