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FORM NO.10-105547-CIWMB M12 2404 519 987654321 <br /> - E Waste Tire Survey & Inspection Report Inspection Report Number <br /> i13- State of California <br /> °7iS21 CIWMB 181(New 04104) Survey Form - Page 1 S - 1 G L 6 3 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / inspection Type (Fill one) <br /> Site Suffix: t 3 I 0 o � I o I f Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: &\"Y\, 1-p0.p��i� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Fz Co n S+Y-4,C, 0 K\, <br /> Physical Address <br /> 560 <br /> Lo <br /> O AA a q5 2q D Inspection Date a q 2 ( o5 <br /> Time In Time Out <br /> Business-Rep J Title ` O AM � O AM <br /> v' C. J/Gl�� P.✓Ot <br /> ® PM v)30r do PM <br /> - <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' a Active 0 Passenger ®Generator ®--Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 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 0 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 ® OthercjN, <br /> ------------------ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A1 HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 0 Other. § ---- -- — - --- <br /> Comments ltaua,,�,d <br /> Uses des Sc�botla_,6 <br /> 1Nasf � -7-✓8 _- r-Emove !aroe <br /> �se � _ 0-. �1 <br /> � Y - (j - ) jYPI ►y► <br /> R <br /> - �ct�SLe_l . /Jo V6&;4i0ns , - <br /> inspection Form Included: p ,q r <br /> p 01 a `�LB(a <br /> Comments Included: 0 - - - <br /> Business Rep's Signature Phone Numbeer/ Insp ctor's S' n ture Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect: X E X A m p 62os1 <br /> LE� 11_ 3 <br /> ® White Copy:CIWMB Yellow Cory Operator Pink Copy LEA <br />