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FLL. <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> 1e1 <br /> CIWMB <br /> f81(New Survey Form - Page 1 i 9 - 1 0 1 3 5 7 8 <br /> CIWMB 181(New 01/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Malts <br /> TPID- j ^ ,+ / h - o / Inspection Type (Fill one) <br /> Site Suffix: r �( y � (f ( 0 Routine. Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: `jG !l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> IV)05- (tetare ngomoi` AVe. -Etc ktO n Ql, � Inspection Date <br /> /`/' !1 Time In Time Out v v� <br /> BusinessTitle o AM / 0 ®AM <br /> ''JC B� <br /> - -- - r I ' O O PM ✓ O PM <br /> Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) 5-V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ®Active ®Passenger 0$Generator ®Outdoor <br /> O I <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Is New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 /> Part B- Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility )=NFORCEMENT STATUS <br /> r y ;;,„ <br /> `A HAULING AND MAtT ftEQUiR>`ME[v1T& ;a z 0 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 ;}3ate m FE" m ' <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB h; <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requir rl for NOV or <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers TMQ Referred 1 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 Compliance - Na Vioiataoga 5' <br /> Q Q Other: § <br /> Commentsv�L%tne >>t5 l blot c{.� <br /> "�n v t r <br /> `on ugs rleY..t 71),R * cpose or- "S�e t&-)7aer mavcl e <br /> tbmer IVW_Gi > s. <br /> N <br /> t�r�� reS�Cac� .����rl� e,�-5 .� ✓i01at%c-"n.st GrL.'!;6';C)WeJ <br /> Inspection FormIncluded:Q <br /> Comments included:Q - <br /> Business Rep's Mgnature Phone Number Ipg toes S _ ture _ Phone Number <br /> - <br /> F � 62081 <br /> INSTRUCTIONS ON BACK EI X /i hk P, , E 1 I I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0634704.0268 <br />