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023120810428 <br /> •ets. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> tint State of California <br /> rrr CIWMB181(New04r04) Survey Form - Page 1 1 5 - 1 0 7 3 5 7 7 <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: ' Z t' D O ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��W -rn�,^ , /� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical d rpt <br /> Street <br /> Inspection D <br /> ��^^,' �, _�L � ate � 0 / � 3 if <br /> City �t6G9CFC�^ State�SZCode <br /> ZipTime In Time Out <br /> Business Rep Title PM m'm PM <br /> I. .Lhi 5.--- --'u'`------..n---Mr...t!twi .. cwtw <br /> _ — 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), S <br /> r�Active ®Passenger ®Generator ®Outdoor <br /> I 1 - 1 O Q Closed Q Altered <br /> GPS Latitude H 1�IL— JJJJ Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> �1 <br /> Longitude - 17-1-1-FI-1-717-1 <br /> —I_F� 1� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 11 <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other i <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notfee of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Eomp11 nee Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements at <br /> Q Q 14 CCR§16459.1-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 FXT) <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 Registered Waste 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 C-ompliance - No 431- <br /> 1010 Q Other: §, <br /> Comments <br /> Inspection Form.Included:Q - <br /> Comments Included: <br /> QI ��et.r'sBusiness ep's Si natu Phone Number snature Phone Number <br /> INSTRUCTIONS ON BACKCOrrec :Wllncorrect: I: X a M P L E 1 Z 3 62081 <br /> ■ Whit Copy CI MB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />