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�', � f1�3g404U0�9 <br /> Waste Tire Survey $ Inspection Report Inspection Report Number <br /> Stat.of 18California Survey Form - Page 1 1 3 - 1 0 7 3 3 6 9 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Managenage <br /> ment Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> f TPID- _ Inspection Type (Fill one) <br /> Site Suffix: ' �' J l W q O ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localj� If Referral,choose referral type(Fill one) <br /> Identifier: SIS(1 TV Q W01 CD-UVj-�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> l�d�pelnc�awl- Tr V ck c f <br /> Physical Address ; 3 9 — - / -�12fu C� <br /> Inspection Date ) / O O <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> / ori odl, of 1 i�eTecG't . O PM O 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(WholelPTE) O <br /> t ®Active 0 Passenger ®Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <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 / Ffl / 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 - - — <br /> 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 /> 1010 1 Other: <br /> Comments 1 _ ; . U • - �^ .� o h/l/ O <br /> QIv,,tns f <br /> �uC(( L methyl r7✓! 7-r►L{� r0 c. $OD SaO 4�'l01 Vres��ti'PGti� �►"f/i <br /> -fir_S- �ni��c�-f-vl��' yiei,�eat� Alv✓�o1c��e�s n a't�. <br /> Inspection Form Included:O <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> ■ (� � EXaML L E 1 2 ® ■ <br /> White Copy CIWMB Yellow Copy Operator Pink Copy.LFA <br /> 1. ---- - --- <br />