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0818204.0222. <br /> = « Waste Tire S� ey & Inspection Repor Inspection Report Number <br /> CIWMState B <br /> 181(New <br /> Survey Form - Page 1 1 1 - 1 4 19 3 6 4 <br /> CIWMB 181 thew 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q Inspection Type (Fill one) <br /> Site Suffix: I0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Sari O � �} Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Ins ector <br /> (� 1 t <br /> �- '� v k�C,_�SSS_V! <br /> D <br /> Physical Address � I 1 L__ n <br /> I S� �)I AVA <br /> Sheet A*__) <br /> — -- --State Z1P O � I � O n <br /> A qs a ,D Inspection Date / / <br /> 0-A l.'Code I Time In Time Out <br /> 1 <br /> Business Rep Title PMm EM : M3_ <br /> v 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) <br /> 'S ff Active Jb Passenger • Generator 0 Outdoor <br /> Latitude i �O Q Closed ®Altered <br /> GPS <br /> i — j • j — I_ —I—_ `__� Q Hauler Q Indoor <br /> — i0 Q Inactive Q Truck <br /> Longitude — I —I I , I I i I I Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer .-,* Auto Repair Q Trucking Fleet Q Government . Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection p Crumb Rubber <br /> Service Station Q Hauler Q Agriculture Q Shredder Q Other t I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 <br /> Q Q 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Date 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 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 e In Compliance - No Violations <br /> Q Q1 Other: § <br /> y, (� n1�,�,Comments \� 1_%� r - - of A-aN���5 - - Q=(k _Y/��' "` 0 W�a—K�lS n _ <br /> Flo <br /> —(kk\orS cDC_&_j gS Q (,cl�W—(\, J <br /> � _ _ cFit, u1 �2!_N � c ' �; . <br /> Inspection Form Included: Q �n <br /> Comments Included: Q . _ <br /> usiness Rep's ture Phone Number Inspe or's Signature — Phone Number <br /> INSTRUCTIONS ON BACK I Co rect: correct: V (� X a M P ;LE ` 11 [2 3 62081 <br /> White Cop .CIWM Yellow Copy:Operator Pink Copy:LEA <br />