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081?3044734 <br /> CBD_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ee State of.anomia <br /> ee CIWMB 181(New04/04) Survey Form Page 1 1 2 10 7 9 16 7 <br /> Calilomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O / Inspection Type (Fill one) { <br /> Site Suffix: jq <br /> / O 16 Routine Q Re-inspection 0-Referral Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: . :a_�AyN_ . Q CHP .Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> -fry_ wAe <br /> Physical Address <br /> LjS. Ctigao Kee_ u� I - -- -- - - <br /> Street <br /> 1 CA 952 Inspection Date <br /> �_l�J , <br /> City State ZIP Code Time In Time Out <br /> Business/Rep TitClej m' <br /> MOPM 0 PM <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) <br /> • i Active •Passenger. •Generator ®Outdoor <br /> I D Q Closed Q Altered <br /> GP$ Latitude Q Hauler, Q Indoor <br /> O Q inactive Q Truck <br /> LongitudeF-I 1.1 1 i I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 0. Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ' pate m <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 EXT) <br /> Q O <br /> 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 ME111111107forcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 10 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Com liance - No Violations <br /> Q Q Other: § <br /> Comments <br /> tT6 z:�V� <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> � EX � � P �L E l �Z 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />