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Waste Tire Survey & Inspection Report Inspection Report NumberSWe ■ <br /> r CWMB181(Omta Survey Form - Page 1 18- 1013692 <br /> Cgrate 181(N. OlrO!) <br /> Cdllomla Inlepnted Waste Management Board <br /> Part A-Survey __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection <br /> d _ a I Inspection Type (Fill one) <br /> Site Suffix: O 6 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: rJrt �QQ r Q CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physicaltdress - O / <br /> suy9i?�fl� �Ox1q <br /> s 2 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep n Title I 10 Am <br /> /QGr Isw l Q sJ / 0 ' / / 0 PM / S / Q PM-­ <br /> Operational <br /> M <br /> I <br /> FpeoneiooM I Status Fill all ire that a I B I all that i ss apply) Ft algthat apply) <br /> I <br /> sme <br /> Tire Count(Whole/PTE) ( y) ( ppy) ( apply) ( ppy) <br /> 0 Active 0 Passenger *Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O . Q Inactive Q Truck <br /> Longitude - — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer IF Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body i Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 111=�sT REQUIRE—IGrE�`�5 _ _.. <br /> 72 ,7. A�951-Waste Tire Hauler Regist,ahon and Transpor of Tires Q Notice Of Violation .Q Extension <br /> 953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q § 2956-Registration/Decal inVehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / I <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB [IJE] <br /> i <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days =�Kued fpr NOV or EX 7) <br /> Q�Q �14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®in Comptianca - No Violationsyy <br /> Q Q Other: § -- + <br /> Comments .kR AIX I <br /> �t�c'r�i' u�2 j° SGL/r�i Yla /vtc ode cc 'Jl ✓,,� Vr e7-1- 'S' <br /> --- <br /> Inspection Form Included: q,Q�ti ry <br /> Comments Included:Q- <br /> Business Rep'sj Signature`' Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK 91 I �� 62081 <br /> ,, EX14MPLE 1Z3 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0633304.0081 <br />