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Gi312U�i��l3i <br /> rrr_ <br /> Waste Tire .Survey &Inspection Report Inspection Report Number ■ <br /> tt Stato 01 California <br /> CIWMa 181(New 04104) Survey Form - Page 1 - 17 - 10 7 3 5 6 2 <br /> Callfomia Integrated Waste Management aoard <br /> Part A-Survey BLUE OR BLACK INK-PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ;z�/! / �i 9 / ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^TA��I r. / �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name tv Y `r , Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date / Q <br /> szy�� <br /> tt; -Mate Z! Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m'm PM m'm ®PM <br /> Operational Status- Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) 1! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active. ®Passenger ®Generator ®Outdoor <br /> t{(I I l Lo <br /> GPS Latitude ,LII o Q Closed Q Altered Q Hauler Q Indoor <br /> LL�� !!!! Q Inactive Q Truck i <br /> Longitude _ =.Ef0 Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) LLL ---JJJ <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Re-treader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®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 ENF�OgCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q — Q Notice Of Violation Q Extension <br /> 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requi ed for NOV or EXTJ <br /> Q Q 14 CCR§16459.3-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 I -IWMB Enforcement <br /> Q O 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 in Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> �nn.t.. r�,r�F,tom_ cr��{l.+..sal�rtt���iskrce/. _/_t�V_R�✓. <br /> Inspection Form Included:Q <br /> Comments Included:Q / GyZU — -- - (p1T0�L 3 <br /> Business Rep' Sig lure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect: ncorrect: EXP <br /> AMLE 3 62081 1 2 <br /> . White Copy.C MB Yellow Copy Operator Pink Copy.LEA ® . <br />