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ue, <br /> Waste Tire Survey & Inspection Report Inspection Report KDmber <br /> !! CIate MM}California Survey Form - Page 1 �I 8 - 1 0 7 9 1 8 9 <br /> CONB 181(New 04104) <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: . Q Z O O Routine O Re-inspection O Referral . O Observation <br /> LocalG� -T If Referral,choose referral type(Fill one) <br /> Identifier: v 0agum Counf�� O CHP O CIWMB O Complaint O Educational Visit.0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> F To k] L <br /> KC 15�I Q11_L t(CQ$_� <br /> I-303 5 . G�n�efokee Lam_, l <br /> Street <br /> � <br /> Inspection Date <br /> zJo <br /> lt����� CA State�IP Lod Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Ra m m O PM m O PM <br /> i <br /> Operational Status Tire Type Business Role. Storage Type <br /> I l I (Fill one only) (Fill all that apply) (Fig all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE)' ;! I ! , `f I Z I Q, <br /> O Active 40 Passenger •Generator 0 Outdoor <br /> GPS Latitude L U LJ_— ' I I IO O Closed 0 Altered • O <br /> U L <br /> TTJJJ Hauler Indoor. <br /> 0 O Inactive O TruckLongitude — O Planned O OTR End-Use Container <br /> Business Type (Fill all that apply)' <br /> 0 New Tire Dealer O Auto Repair. Q Trucking Fleet O Government O Retreader O Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station e Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 * 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 for NOV or E)M <br /> O O — -- - - - <br /> 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 Compliance - No Violations <br /> 10 1 O 1 Other: § <br /> Comments t�cxaty,�sY�S�ot,�t.l��l1__Per�or�d -Aiinl, d�. � �Lo. �n1�ot,�.tld�c�rSs_I0 <br /> NQrAAA ��rs�, ,nc.—fie <br /> _ �r d��v Albec- s <br /> =C1r�_7orL;,,�s,ste�tre Y Alt --1LPA-g1iv1EA <br /> l.,ec a aat Cl'%k bl e 4nr Brei, nn—r 1 <br /> Inspection Form Included:O <br /> Comments Included:® ` ""� a 0. yam" 3178 <br /> Business Rep' i;nature Phone Number 1 or's Signr Phone Number <br /> INSTRUCTIONS ON BACK orre Incorrect:X) �J 0 X A X14 P 2 3� j 62081 <br /> ■ White opy:CI Yellow Copy Operator Pink Copy.LEA ® ■ <br />