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ru. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> irl state of California <br /> CIWMa 181(New 04104) Survey Form Page 1 3°- Q 5 <br /> Celifamia Integrated welts Management Board <br /> Part A-Surve _ BLUE OR BLACK WK PEN <br /> Business Profile Inspection Details 0626 5000) <br /> TPID- v Inspec on Type (Fill one) t <br /> Site Suffix: 3 Q O ( tine Q Re-inspection ®Referral Q Observation <br /> Local �7' r Referral,choose referral type(Fill one) <br /> Identifier: I Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name JIS U Inspected By Inspector <br /> Physical Address I mv <br /> I 51 32 �>rt�7� <br /> Stroet <br /> IS20,5- Inspection Date <br /> B.0 Stare 1 <br /> I Time In Time Out <br /> zov� <br /> Business Rep Tithe �r�,�- O AM O AM <br /> Vj�LY __._L.OWE`u. J m m O PM ELI: O PM <br /> - - -) - -- Operational Status Tire Type Business Rote Storage Type <br /> ry (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r 1 'f "! <br /> C)Active ®Passenger ®.Generator 0 Outdoor <br /> -- - O Q Closed Q Altered <br /> GPS Latitude O Hauler O indoor <br /> _ -- Q Inactive Truck <br /> -`-'O <br /> Longitude - Planned ®OTR O End-Use Q Container <br /> Business Type (FII all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture O Shredder 0 Other L 3or <br /> _ I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste_Tire Haulers. Compliance Deadline <br /> O O PRC§42956-RegistrationlDecal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 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 /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> O Q 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 0 In Compliance - No Violations <br /> 0 Other: §,-- 1 - ----- m�,L �-�•(� /1 �-�p �1. <br /> Comments!•fb„in(�,rl} <br /> v1�1al_�� olsf9Ai�'Q� 1Ir- �F'1 - ,J l.I _ <br /> hiSrj,cC;nyj rP.tl t .4 r t h ►G�S c' <br /> AOL— <br /> Inspection Form Included:Q <br /> Comments Included:#- - Ins t r s _ -ature Phone Number <br /> �Usiri <br /> ss i na P ne Number <br /> �( 62081 <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: ( �J E X R P L 1 2 3 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA <br />