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� fcr�<�fslbl�feJCrf�r.::..$r1�r�r���f�rrfarrs f.�� i:�.:.;:�..1.urz ,••...... <br /> S-:-ii iii.•JL✓:�-..__�-__.- - <br /> ■ LL „ Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B 181(New 04104)California Survey Form - Page 1 1 1 0 7 9 4 8 9 <br /> CIWMB <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Suryey et -- <br /> _ Inspection Details <br /> Business Profile <br /> TPID- Lk 0inspection Type (Fill one <br /> Site Suffix: 0 <br /> ` O 9 Routine Q Re-inspection Q Referral Q Observation <br /> ® If Referral,choose referral type(Fill one) <br /> Local Identifier: SW1[� GCACgln lkJl.�t� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address ESQ <br /> CA a�5 Inspection Date a � O Q— <br /> S�Q C� &0 J Time In Time Out <br /> Business Rep Title 1 f1 O PM ' rJ Q AM <br /> l•J l ��- <br /> PM <br /> r ` A nD <br /> S �n� G" [ � � oz- m��— Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , <br /> Active ® Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> D Q Inactive I*Truck <br /> Longitude — Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) -Dismantler <br /> -le -- - <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 S Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and-End-Use Facility __ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q 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 ® PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q ® 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ti <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Other: § — <br /> Comment�' ,) <br /> � ii?! - V s Vf1lS L{ C� -s1fJt !t� — <br /> Inspection Form Included: Q _ <br /> Comments Included: 16 <br /> Busin s s <br /> _ P n e Number � Inspect 's ignature Pone Number_ <br /> ure —_ - - -- <br /> _ - ( VI F .X i> �r�i 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (, ,+ �_ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy: <br />