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T <br /> r <br /> =I ;I Waste Tire Survey & Inspection Report . Inspection Report Number <br /> State <br /> gratedCalifornia <br /> Survey Form - Page 1 F1 9 �- 1 01 3 7 9 2 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile :77LI Details <br /> TPID- L ''1�O�� � � � _ O � Inspection Type (Fill one) 1 <br /> Site Suffix: III 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S( ��S 1,' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected BY Inspector <br /> ector <br /> Physical Address <br /> 1 111,1'7 S, <br /> Street Inspection Date <br /> S-� o h CA R7Zo(o I CY 1L/ <br /> City State ZIP Code Time In Time Out <br /> Business Rep off Title Jl m • 0 AM 0 AM <br /> O PM m • m 0 PM <br /> Operational Status Tire Type Business Role Storage Type- <br /> Tire Count(Whole/PTE) 1 O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t le Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed ®Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> -- ,O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR ® 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 /> i <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS J <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 / Ffl <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 /> 0 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 <br /> ® In Compliance - No Violations <br /> O 0 Other: § <br /> CommentsQ _WA <br /> I]�IQ'3�O I��n'1Q(XL7�• <br /> Io i +�Ses r r -fv �u�ac ►'epfod <br /> - <br /> - rub�2Pf is .shy Irl 0-n.s �?y 90L, o. <br /> advh and mare ts-h is not d h2 in rc ti s Iraft -y -- t Aa <br /> Inspection Form :nc <br /> ncluded: 0 c <br /> Comments luded: W, Rep;A—', <br /> +r a�f " '`6� <br /> Business ligature Phone Number s tor's gnature -Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: '�(( FENTAPIPME1 111213162081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />