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t1�� ��U�UtJ�3 <br /> =Er . Waste Tire Survey & Inspection Report Inspection Report Number <br /> 1ed` Stateof California _ T w /It 69 <br /> ^ ^ <br /> CIWM8181(New04/04) Survey Form - Page 1 1 (r <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: �I O C? 1 I ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> �. P Y Inspector <br /> (Physical Address L <br /> 91 <br /> lLJI 1 <br /> Street <br /> Q Inspection Date I'L� !/_j� <br /> _— -153T 6J Time In L Time Out <br /> City State ZIP Code <br /> Business Rep Title0 AM 0 AM <br /> ®PM 8 PM <br /> i <br /> �r��--- ny�' - - 5�-- - Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all.that apply) (Fill all that apply) <br /> v O ® Active ® Passenger ® Generator ® Outdoor <br /> Latitude �^ Q Closed O Altered <br /> GPS -I� Q Hauler Q Indoor <br /> __ I 0 Inactive Q Truck <br /> Longitude - I 1 i , I I I Q Planned . Q OTR 0 End-Use Q Container . <br /> Business Type (Fill all that apply). . <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet.. Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler, Q Agriculture Q Shredder 0 Other I I <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and:End-Use Facility ENFORCEMENT STATUS ¢�. <br /> .. <br /> 'V LING NN.. .D-MANIFEST"REQUIR-EMEN�T�S <br /> Notice,Q <br /> otic®.Q ftVxarrwioat,#a' <br /> n� Q ension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers.. w,Compliance�Deadlineq <br /> O O PRC§42956-Registration/Decal in Vehicle " ' ' <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements $Date <br /> 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> ' �� (Required for NOV or�Jz <br /> 14 CCR P P 9 Y 18459.2.1 -Submittal of Comprehensive Tri Logs within 90 days <br /> „ <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 HaulersQ`Referred/CIWMB10Enfdi' lntl� ,'R <br /> wa_ �r <br /> Q Q 14 CCR§ 18461 -Manifest System.Requirements for Waste Tire End-Use Facilities <br /> ' x. <br /> 14 CCR§.18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. "O�in aCoinplianc10 <br /> etNoViolati+ns <br /> OO Other: § ___. . ,. »e .E'a.�Nt�cxesa• ?uz <br /> Comments <br /> V <br /> Inspection Form.Included: Q <br /> Comments Included: ® Bu - -ad 93 — ---OXt ZE--'�o? <br /> � <br /> siness ure Phone Number In c isi aturb <br /> Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co recti ' Incorryect ,'aX �:P 3 <br /> White Copy" Yellow Copy:Operator Pink Copy:LEA <br />