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Waste Tire Survey. & Inspection <br />Report lnspectiUlQe$�AARA&V <br />r� State of California <br />r CIWMB 181 (New04l04) Survey Form <br />CaIHornla Waata Management Board <br />- Page 1 1 4- 1 0 7 9 1 8 5 <br />Intag.1ad <br />Part A - Suxe _ <br />Business Profile <br />BLUE OR BLACK INK PEN <br />Inspection Details <br />TPID - <br />site Suffix: I 1( a Q ` <br />Inspection Type (Fill one) <br />0 Routine Q Re -inspection Q Referral Q Observation <br />Local <br />i If Referral, choose referral type (Fill one) <br />Identifier: SQ(� �QQOat{Z Our t t y <br />ll 1 <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />I PAZ TI_�e 'ERI <br />Addressr�� <br />-[Jo11cPhysical <br />Stl <br />LI w'i_LuAs� <br />Street <br />_ <br />Inspection Date <br />I I ad, a52_q.aj <br />_CA_ <br />City State ZIP Code <br />Business Rep Title <br />Time In Time Out <br />0 AM 0 AM <br />I._/-il_b-1-•n-O PAZ '�--l�J-'�<r I <br />m m O PM LLJ m 0 PM <br />Operational Status Tire Type Business Role - Storage Type-- <br />Tire Count (Whole/PTE) tf <br />O <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />0 Active Passenger & Generator . Outdoor <br />Q Closed. Q Altered <br />Hauler Q Indoor <br />O I <br />GP$ Latitude [_ I { I iQ <br />LL —1-1�0 <br />Longitude - l�.F t � <br />l <br />Q Inactive Q Truck <br />Q'Planned Q OTR Q End -Use Q Container <br />Q Retreader Q Dismantler O Tire Derived Fuel <br />_ _ <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government <br />0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection <br />Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder <br />Q Other I I <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />! HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 -Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers, <br />Compliance Deadline <br />Q <br />Q <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / m / m <br />Q <br />Q <br />14 CCR § 18459-1 -Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 -.Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred t CIWMB Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire -Generators <br />• In Compliance - No Violations <br />Q <br />1 Q <br />1.0ther: § <br />Comments <br />Ro�ti'�ne.�--��s�eci_►on--�ec-�oc.f�-^ed �-h_is—cl.ofe—�4e.--�o_Ilow.t.r_�—t,.�o�Ap�cc�� <br />�;� any_a�,_���1�yJ_��.r_�._-0W�,�6.►, �a�, �t��.a��_ <br />Cir <br />r�.oE c��eca?fe._,�nar>�_wns�e-_1-�re� � waste, �►cesat.e�hauled�oit-srl-e—r�Pc�x ��iat�t <br />L)ir users__ll�ma�e Alber�os "iit or�io�oc��or�ld%ec{ <br />Inspection Form Included: Q <br />1 z 4�Q' (Za4J <br />Comments Included: Q <br />— <br />Business Rep's Signature Phone Number I or'stnLe Pff_hone Number <br />62081 <br />INSTRUCTIONS ON BACK Qv:0 Incorrect: ( X A Jdi 1 ;2 3 <br />. White Air CIWt 8 Yellow Copy Operator Pink Copy LEA <br />