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0�03�;3aJ31<Q <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CFWM 181(New SurveyForm- Page 1 1 3 - 1 Q 7 9 4 2 4 <br /> CIWMB 181(New 04/041 - <br /> Califomia Integrated Waste Management Board <br /> Part A-Surve _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - Inspection Type (Fill one) <br /> Site Suffix: , 4 1 0 / 3 ' - , ®Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifiec. /f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> i sa�vvt F'r e J k,_T �rtttic L t c . 13 _ D <br /> Physical Address <br /> Street <br /> Inspection Date <br /> L ��ocl�e�tw� GQ 9540---1 <br /> City State ZIP(;Ode Time In Time Out <br /> Business Rep Title F]—]OAM O AM <br /> ®PM ®PM <br /> Operational Status Tire Type Business Role. Storage Type - <br /> Tire Count(Whole/PTE) I. `I` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t� ®Active Q Passenger ®Generator ®Outdoor <br /> Q Closed• Q Altered <br /> GPS Latitude U <br /> OH.auler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude - , Q Planned Q OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0;Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service station Q Hauler Q Agriculture Q Shredder Q Other <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 Extenslo <br /> Q Qi PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompi ance 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 FXT) <br /> Q Q 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 Q Referred/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 - NoViolations <br /> Q Q Other: § <br /> Comments �/!7._ L 1_ �rh <br /> /_ <br /> `l�l [.0 C- <br /> _WALSInf- -1y1___A!Trib_f-C.4 - f b'1,— �fKMt��( j�l�vsGtJltr} �USl1�t/r tAJ1��TSA-04-JCtXy1�1U. <br /> — 'RFs-r�S-r 0 —ram �'r�t41 rz�r�e(its—mn c;1'ery, <br /> r1nG�Yt_CtMG��� -s -�oy <br /> Inspection Form Included:Q <br /> Comments Included:Q,Bus'- 1= `]- 1 `Ld <br /> iness iikep"s Signature Phone Number Inspectors Signature _. Phone Number - -' <br /> INSTRUCTIONS ON BACK Co rest: Inrt: )f A M R L Il ;2131 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy.LFA ® ■ <br /> l _ <br />