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` = Waste Tire SUS vey & Inspection Report Inspection Report Number <br /> F777 State of California <br /> f1�' <br /> 0 Survey Form - Pa 1 4 - 10 0 6 5 7 7 <br /> CIWMB 181 New 04/04) Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile - - -- <br /> Inspection Details - <br /> _ <br /> Site -Suffix: <br /> SInspection Type (Fill one) <br /> Site � � �� '� � � - � <br /> -- ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral t <br /> Identifier: (� - ype(Fill one) <br /> GAAv Q CHPQ CIWMB Complaint 0 Educational Visit Q Other <br /> - - - <br /> ' Business- U or Facility Name - -- - <br /> Inspected By Inspector <br /> �- L t <br /> P � <br /> hysical Addr s 1> <br /> �-� k-117`��� 11i t-a r i <br /> -" Gl <br /> fc1 ,� Inspection Date / O / O �. <br /> �-�1 <br /> 1 <br /> Business Rep Time In <br /> Title Q AM Time Out <br /> "" V 1 l7 C> O AM <br /> �A►^^W` 4*PM V > S ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) i <br /> I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator O Outdoor <br /> GPS Latitude O Q Closed O Altered <br /> ® <br /> 0 'i Q Inactive O Truck Q Hauler Indoor <br /> Longitude <br /> Q Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ®Auto Repair O Trucking Fleet O Government O Retreader <br /> O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body ® Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station O Hauler O Agriculture O Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility — T -- -- <br /> - - ---- _ _ _ _ ; ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS - .....— <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> �O 0 PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ,;y ��(Regdtred,�orNO.V <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ee j d 11 , B ii otcFn 11t <br /> 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators $ ` <br /> O1O <br /> Other: § <br /> In,Compliance - No Violations <br /> _. <br /> - —. <br /> Comments <br /> `4 v C �,c � W I�s�-t- l _ _VV�_cw,,_ <br /> - <br /> �- �v���-� j� � i � was, ZS 'C>5' r�cz b <br /> � y `� - - 13-t11 <br /> C TL - - <br /> u <br /> Inspection Form Included: <br /> Comments Included: -LRep's <br /> - -�76=175 A � �b <br /> i nature IInspector's <br /> 9 Phone Number Signature Phone Number_ <br /> INSTRUCTIONS ON BACK `Correct: Incorrect 62081 <br /> -- - X �' V E;XRMP L E 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® j <br />