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■ <br /> Waste Tire SOey & Inspection Repo Inspection Report Number <br /> W"�' <br /> a- State of California > f1 7 t'4 (' t <br /> � CIWMB 181(New 04/04) Survey Form - Page 1 3_ �) . Z <br /> California Integrated Waste Management Board a - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- 1 ! -, Inspection Type (Fill one) <br /> t I R Q Routine Q Re-inspection Q Referral % Observation <br /> a 'J <br /> Site Suffix: �I- �. Cj �l� � � Q <br /> Locall� If Referral,choose referral type(Fill one) <br /> Identifier: Ck n 7o i - t t 1 �\� G oU t 1 1 <br /> � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - <br /> 1:11 L <br /> Street <br /> Inspection Date kLls <br /> 2-1Q�rJ <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM t — T O AM <br /> PM ... <br /> 7­1 <br /> . '- O PM <br /> . Operational Status Tire Type Business Role Storage Type <br /> ' (Fill one only) (Pili all that apply) (Fill all that apply) (Fill all that apply)' <br /> �-( ® Active Q Passenger ® Generator Q Outdoor <br /> Latitude g ` I Q Closed Q Altered <br /> GPS <br /> EIJ �_ _. _�C__�L Q Hauler Q Indoor <br /> g— 0 Q Inactive Q Truck <br /> Longitude - 1 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 <br /> aP"B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Fv_F_A HAULING AND MANIFEST REQUIREMENTS <br /> 11 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / 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 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 Compliance - No Violations <br /> Q Q Other: § -- - <br /> Comments �{ <br /> ori 5� rrfr 'x_1'1 lg/cam rli - t -t � <br /> _gyp _ `t c� - _ t F4 C«V__ ...-�- <br /> a <br /> Ins ection Form Included. QI <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector s Signature Phone Number <br /> �`" - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 62081�,. p �. � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® 0 <br />