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_ 09182 �4Q395 <br /> `eoa Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CrWM Survey Form - Page 1 I - 1 0 7 9 3 3 5 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: a 13 �1J 3 O I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: sat) Jot�q Gu, _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 �_ Inspected By Inspector <br /> Physical Address- vi I I <br /> Au-)a� <br /> a- k--i <br /> Street <br /> Inspection Date <br /> State ZIP Code Time In Time Out l v I JJ <br /> Business Rep Title 0 AM 0 AM <br /> 0w.,K/ EX 0 PM O ® PM <br /> _ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � . <br /> Active PassengerJ&Generator ® Outdoor <br /> GPS <br /> Latitude i I .I I IO 0 Closed 0 Altered <br /> � 0 Hauler 9 Indoor <br /> - 0 Inactive 0 Truck <br /> I I I Container <br /> Longitude _ I I I I, I t I I I 0 Planned 0 OTR End-Use 0 <br /> Business Type (Fill all that apply) 111 11 <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 l l <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder OtherILAfastl1(�� It 44i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ! <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 Ffl / M / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 /> 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 O In Compliance - No Violations <br /> 0 1 0 Other: § <br /> Comments <br /> _ ons or acmes o _c�oa un_, <br /> I <br /> Inspection Form Include <br /> Comments Included: 0 - Vpe , <br /> ep nature Phone Number InsSignature Phone Number <br /> JV` <br /> INSTRUCTIONS ON BACK C rrect. Incorrect: q � X 1i. P 'L 62081 <br /> White Cop CIWM Yellow Copy.Operator Pink Copy:LEA <br />