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• <br /> section Report Number <br /> Waste Tire S y & Inspection Repor p p <br /> F; State of California <br /> � aa � I 1 <br /> -ems CIWMB 181(New 04/04) - 1088357 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details T <br /> TPID- e� 7 !; / Inspection Type (Fill one) <br /> Site Suffix ; f / <br /> _ (S Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local u V If Referral,choose referral type(Fill one) <br /> Identifier: <br /> t 11 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> Physical Address ----G' <br /> Street 1� ("'• <br /> z.. 7 Inspection Date t / ,� / FL t I <br /> City - Sfate ZIP Code Time In Time Out <br /> Business Rep Title f. O AM Q AM <br /> o ` - <br />,i t ►�70 J ( Q PM O PM <br /> 14C (6 i- -- <br /> 1__—.. �,— <br /> 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 /> CI 0 Passenger 0 Generator0 Outdoor <br /> C_ ET­F]Latitude �O � d 0 Altered <br /> GPS � � 0 Hauler 0 Indoor <br /> -- Inactive.- 0 Truck <br /> (--_--�--�---1--�— O <br /> Longitude — 0 Planned 0 OTR U End Use (� 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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> 11 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> I <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 0 Referred)CIWMB Enforcement " <br /> s,l 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> f I 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0 0 Other: § <br /> + 1 + (� <br /> Comments F(�('l l•l! k4i'l(.+� ft{�(_:J✓l X, /E 1 '.f G� t'• 7-S �c k t'l['�4 � " (`Cl k (i t I l'(e .r` Ctrt_ i <br /> �j Vte(�J bvi page b d�tk(e.S,+ fo(N,Dyt¢y)Cj orl-�rl , M0 vw <br /> oh(,- oy -two, t* -t'j we rkCIyige fit Averq r ' <br /> �? c. E 1 P e 4 c rl 4{-o r) +,n 1 ( i -_)(.rF: <br /> !. <br /> ction <br /> PRI <br /> 3fespeCommen4s included: 0 _ � ti„ { <br /> Di Business Rep's Signature Phone Number Inspector Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: 62081 <br /> 6 ; , P » f I I <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> i <br /> i <br /> i. <br />