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eae, <br /> Waste Tire Survey & Inspection Report Inspection-R por�NumberState . <br /> ClWM 181Cal(New Survey Form - Page 1 1 2 - 10 7 9 4 6 4 <br /> CIWMB 18f(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK.INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix:. it O 3 S 1 O + ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -�e,�.�r Q CHP . Q CIWMB Q Cr <br /> omplaint Q Educational Visit Q Other. <br /> Business*or Facility Name 1 v — a Inspected By Inspector <br /> Lid I <br /> Physical Address 3 a�J - LO l <br /> l 4"d, I � L�t►�w,alq,�W7�C4i.. <br /> l )7-cm 5 �axo.lCe�_Lr�_, I <br /> Street / <br /> Inspection Date <br /> y Lit p <br /> City d C State Z!P Code I Time In Time Out <br /> Business Rep p Title 0 AM 0 Am <br /> m'MOPM mO PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> L��O <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude W, T o Q Hauler Q Indoor <br /> �(�1Q Inactive Q Truck <br /> Longitude - I711.I I I L I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> Q New Tire Dealer -Q Auto Repair" Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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 p Referred I 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 /> .. �rts�c,�i csr,—GY+ `�'�S deefa�. �-(i,cS—�134AZ—•-f�t�w4c f c_�i1� <br /> _�LspQj&J2. Pc,:cn—t�cc tqt—cmu_k— - <br /> Inspection Form Included:Q cb�//n,..-- p 4 <br /> Comments Included:Q X( �'�Y�.`1i�.�Q %(7� �6 Z 7✓ <br /> Business Rep's Signature Phone Number Insp�Si ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: NJ Incorrect: ( E X A Ah P I L I El 111213 12081] <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ■ ' <br />