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■ a. �s� <br /> Waste Tire S y & Inspection Repo tt Inspection Report Number <br /> IiH State of California I 1 � 114 3 5 0 7 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board _ BLUE OR BLACK INK PEN <br /> Part A- Survey _ _ <br /> Business Profile Inspection Details <br /> TPID- ^ � � - Q I Inspection Type (Fill one) <br /> Site Suffix: I d 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa U, 4 (0 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> p u 1e () i rC_S l (� <br /> Physical Address l &nCA WC�I-f'v <br /> To _ o Inspection Date / I _ V <br /> Time In Time Out <br /> Business Rep Title 1O AM AM <br /> 5 0 P C1 U 0 P <br /> ------ <br /> -� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1� 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered 0 �/" <br /> (�p� 1`�/A 0 Hauler�A 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> • Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 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 <br /> In Compliance - No Violations <br /> 0 1 0 1 Other: § L --- ------ - - <br /> Comments i 1 <br /> ba Vi a Ui n ns 01 u 1r_� J tAo celn• <br /> C4 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 -��O �lz — _(awl Kb O'3� _ <br /> _Business Rep's Signature Phone Numbers Insp or's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect � i , 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.L . <br />