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ALa <br /> = ,. Inspection R��d <br /> Waste Tire Survey & Inspection Report <br /> ■ Ir State of Califomia <br /> 11r CIwMB181(New 04104) Survey Form - Page 1 1 1 - <br /> 1 01 31 9 9 <br /> Caldomle 1;n raled wash Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 71-Z <br /> Inspection Type (Flll one) <br /> a]SiteSuffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1 5441 "Q _':i17 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V inspected By Inspect r <br /> I <br /> IPhysical Address o �cl9 a$y lw/ <br /> I /00/ W <br /> Street v Inspection Date W (' <br /> I S � <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> m0 <br /> PM [T]• 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(Whole/PTE) I . I �I� D' <br /> r I r •Active Q Passenger 0 Generator ®Outdoor <br /> GQS Latitude 1- D Q Closed Q Altered <br /> I I i Q Hauler Q Indoor <br /> _ L A Q Inactive ®Truck <br /> Longitude - I I I I Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) III <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 0 Other L 1A Z_e <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 M <br /> Q ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 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 - No Violations <br /> Q Q Other. § �-+ <br /> Comments TPl�/ /!/Je21a?_a <br /> �l� - i�Ce /yC'GI��/8 ys9 r �P rp•o,��,'l.�e �'�-t�,'�/ P�"�.�''� ti. est <br /> Inspection Form Included:Q ���J'�T //�//�-/� /�/8�O <br /> Comments Included:0 L gn^ e _ IGs LO <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 0')�j E x a M P E 11 2 3 62081 <br /> ® ■ <br /> ■ White Copy.CIWMB Yellow Copy.operator Pink Copy:LEA <br />