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rea_ <br /> Waste Tire Survey 811 Inspection Report Inspection h ReSport Number ■ <br /> YY <br /> State <br /> grat!dCalsteM Survey Form - Page 1 1 - 1 0 7 9 1 6 6 <br /> CIWM'181(New 04104) <br /> California Integrated Wasta Management Board <br /> Part A-Survey. <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �Jo <br /> p S _ O / Inspection Type (Fill one)Site Suffix: I , O 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: . S Af t4_ 6 uN 4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name a J Inspected By' Inspector <br /> I �Anl b%Lr�J <br /> Physical Address <br /> - <br /> Street �J <br /> al <br /> ��Z/LSI Inspection Date <br /> City State ZTFs <br /> I C/�V-• fi 7(CodeJI, Time In Time Out <br /> Business Rep Title O AM O AM <br /> EI] <br /> Te / lJ.tI�fs c 1i'�'�� m:LlO PM 'm O PM <br /> ___ re.J 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 /> I / 10 0 Active Passenger 9 Generator 0 Outdoor <br /> GPS Latitude II O 0 Closed 0 Altered <br /> Q Hauler Q Indoor <br /> _LLJ � IO 0 inactive 0 Truck <br /> Longitude - I 0 End-Use 0 ContainerI Planned OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body •Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other i I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> PRC§42951-Waste Tire Hauler.Registration and Transport of Tires Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0. 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / M / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> L � <br /> �ar�rRif - ( - �H-17A---- C.�,cr1n GCS <br /> K/GVt'i— f7�Gds —�A �iOS7r-�/. _ OO� <br /> Inspection Form Included:0 <br /> Comments Included:0 <br /> Bu ness Rep' Signature Phone Number Inspector's Signature Phone <br /> 3 Number <br /> �! E X 1 62081 <br /> INSTRUCTIONS ON BACK Correct:!] Incorrect:X)0 lrJ .A Ah P'L E 2 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />