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Gis`sSu4i)i�s3 <br /> 01,,c <br /> Waste-Tire Survey &Inspection Report Inspection Report Number ■ate WMS 1 allrorntaSurvey.Form Page 1 1 8 . 10 7 3 4 6 4IWMB 181(New 04104)Ctegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN - <br /> Business Profile Inspection Details <br /> TPID• O I Inspection Type (Fill one) <br /> Site Suffix: 2 5 D is Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C � -�yc , y��► Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business orFacility Name. Inspected By Inspector <br /> 1 4_;t <br /> Physical Address -/ O j <br /> Street Inspection Date Z p <br /> I Sam „ CA 95,20 ` I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m' ®PM m'm ®PM <br /> perational 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 /> ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) -riL•); f <br /> Q New Tire Dealer .Q Auto Repair Q 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility' ENFORCEMENT STATUS f <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violatn <br /> io <br /> QQ Extension <br /> 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q' Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EXT) <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 t®In Compliance - No Violations <br /> Q 1 Q Other: §, <br /> Comments <br /> � <br /> —T-Oi�ft T-I.(�S_�'_�Y2�S-_.-_•Sc-r�n�� yr,�_��.p�—�[y�-y4-�c.Qrku�rG.� i'�bC�C(-0. <br /> �-- <br /> -C�TLs vtzvr ___tw�JvY7_tcr�.te_cI Na=4tlis- --o-1�-S�mrccl - of VI'k ln'Asn <br /> - E <br /> Inspection Form Included:Q i z 5el <br /> Comments Included:Q <br /> Busi ss Rep's.Signature Phone Number_ Inspector's Signature. Phone Number <br /> INSTRUCTIONS ON BACK Correct: Inco . E X A M4 P L El 1112131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />