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osoroo�o�ss <br /> Nr. <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> MState of CalHomia Survey Form- Pagel i 3 10 7 3'5 91 <br /> CIWMB 181(New 04104) <br /> Cellfamla Integrated Waste Management Board. <br /> Part A=Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Sum, 3 s-1 1, <br /> � 0 Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Save -�y0.�wx•n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam— IJ Inspected By Inspector. <br /> %,t�FcJr`rtwhl���t.e, Q�,Pcr <br /> (Physical Address I .3 5 - f 17 <br /> Lf_b�c�I3� � <br /> L-3 SSo f3o���n� �at• I <br /> Street <br /> Inspection Date <br /> City Zip Code Time In me Out <br /> Business Rep Title O AM TiO AM <br /> ®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 /> r� O Q Closed Q Altered <br /> GPS Latitude W_ Q Hauler Q 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 /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMEN1_S1T+ATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 (Required for NOV or FX>) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for RegisteredWaste 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 ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �+ <br /> ..T t _ }_._�.y_t '�fna h firs r• IZ.nre,n...i_ `/irtdAJc�. Nk <br /> -- /yo V16 't'rh1S _ <br /> Inspection Form Included:Q <br /> Comments Included:.Q LG'g"-ObZ3 <br /> 13 #Re 'WnPhone Number Inspector's Signature... Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON.BACK Correct: Incorrect: E X A M P L E <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA- ® ■ <br />