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110: <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWM 181(NCalifomia Survey Form - Page 1 1 3 - 10 7 3 6 0� <br /> CBNMe 181(New nage <br /> California Integrated Waste Management Board <br /> Part A:Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details ' <br /> TPID- O y / D I Inspection Type (Fill one) <br /> Site Suffix: b ®Routine Q Re4nspectlon 0 Referral .Q Observation I <br /> Local /1 � If Referral,choose referral type(Fill one) <br /> Identifier- ��yr► t � � f ix,�.n. O CHP O CIWMB O Complaint O Educational,Visit.O Other <br /> Business or Facility Name o Inspected By Inspector <br /> I i2 I _' _AA,.' G - [/TO <br /> Physical Address !/ /' fS I 3 / / Q <br /> � Street �7 <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m' FTPM m'm ®PM <br /> 0 AM OA <br /> I-_+Ol'�"��nGt,V� �•�di_ll L--'�'�� __ ,t Operational Status Tire Type Business Role Storage Type'. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 1 ° ®Active ®Passenger. ®Generator Outdoor <br /> I O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> JJJJ <br /> O O Inactive O Truck <br /> Longitude - � 1:1O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) L - <br /> ®New Tire Dealer 'O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> ®Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other l <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULINGAND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O 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-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required(or NOV or EXT) <br /> O 0. 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§'18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O . 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In C-ompliance - No Violations <br /> o O Other: § <br /> Comments <br /> 5_V,.t.rw��� - <br /> -L�j <br /> - —t�-rLrn�-u-='-�''z'�cP/—lsdatd(---5}r;-GILQaI_� C_1�lr,H��tQ/ -%�rs_�/drCLEIS• �'L^f/t <br /> [JlJ__ C. ✓ <br /> Inspection Form Included:Q <br /> Comments Included: <br /> O <br /> BusinA6R.p'signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C-orreet:� Incorrect: X A M P [l, E' 1 j2 3 <br /> ■ - White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br />