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=qeo. ispection Report Number <br /> Waste Tire Sur & Inspection Report <br /> 10� State of California <br /> ClWMB181(New 04104) SUrVeyForm - Page 1 I 1 - 11412 9 8 <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: h ja It Routine Q Re-inspection 0 Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `\�� - <br /> _ Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code {Time In Time Out <br /> Business Rep Title fAM AM <br /> Ll <br /> I� �g 0 PM I� , L Q PM <br /> ,SU --- <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) O <br /> Q Passenger <br /> Generator Outdoor <br /> i D Q Closed Q Altered <br /> GPS Latitude I L—I ! .�� 1 O Inactive Truck Hauler ® Indoor <br /> L_J f�_ ®o <br /> Longitude I I , i I I I Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all-that apply) <br /> Q New Tire Dealer 0 Auto Repair ® Trucking Fleet Q Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer 0 Auto Body O Car Dealer O Collection 0 Crumb Rubber . <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder O Other L_ I <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility =ENFORCEME'N"T�STAT.tJS � r <br /> . , ,w ,a .�.�= •�w+ 'w.z�r -+m,ear za$r.{!F�a# x•"�sa�-r; <br /> 1% A HAULING AND FEST <br /> MANI "REQIRENTS ; -> � ..; ;¢g, �� � � , ��t� x <br /> ..,_� .. . m .,,_„ ... UEM <br /> , , . __... � Notfce Of V olatton .Q Extension V, <br /> O O PRC§42951 -Waste Tire Hauler Registration and.Trans ort of Tires « <br /> PRC§42953 Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> i PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements ;Datemm�/� mg� m � <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> �(Requnec/=tor N01/or�DCT) � ", <br /> Q Q 14 CCR§18459.2.1 Submittal of Comprehensive Trip Logs within 90 days. <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs fora years ?� F :a�`aar�r <br /> �a� !� Y,�i4�+gd�f^* �y.kdA/g�3 '�� YS$3�y� a"+�y• <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q�Referred/�CIWMBE�nfo�reement ; <br /> 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities � .. <br /> 0. Q 14 CCR§18462-- Manifest System Requirements for Tire Dealers or Waste Tire Generators '� � w � a' § <br /> ® In Compliance No�yiolatiohp <br /> O O Other: § «. l <br /> Comments 1'lP i>'t 72>n L)Re 0-n -fA.1 I L- _C\ <br /> Inspection Form Included: Q ( c/,(� 9 <br /> Comments Included: Q -- --- I-1-�- U 411--�14--rc <br /> ��sin s p Signature Phone Number sp cto s ignature Phone Number <br /> 4a� N*' �vJsn' s 62081 <br /> INSTRUCTIONS ON CK `Co recIncorrect "{� E1X A MIPIr I Z 3 <br /> White Copy: Yellow Copy:Operator Pink Copy:LEA, <br />