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Waste Tire Sui Bey & Inspection Repo Inspection Report Number <br /> - F33 } <br /> tit State of Callfornia �p }�`�910 ! �}} t <br /> CIwMB181(New04/04) Survey Form - Page 1 �'' L <br /> California Integrated Waste Management Board <br /> Part A.Survey BLUE-OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r_ r Inspection Type (Fill one) <br /> Site Suffix: W i ' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �a(� J 6 uta -IJ�N 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I m D 1.J� 7 ES(QjV <br /> 5_ Sa_(,t G,`(y\C.t 1 i 0 J <br /> G� Inspection Date <br /> �l 1_11 Time In Time Out <br /> Business Rep Title c O AM F %0 AM <br /> C ,- I J O PM 1 D J O PM <br /> C��Q_ kon �t1�5 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) f 5 <br /> e Active ® Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned S OTR 0 End-Use (6 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> -Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 -- <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 is In Compliance - No Violations <br /> O 0 Other: § L- - <br /> --� � 1 1 �],\_ AOL Comments �c'•('�Q f t�lcl� 11� l�i n 4 1�1Cc��_S 11 0&4 . <br /> c�onct'n <br /> jdo <br /> Inspection Form IComments Iness Rep's Signature Phone Number Inspe is Signature Phone Number <br /> - • 62081 <br /> INSTRUCCK Correct: Incorrect: ( ) I A ® ■ <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink opy: <br />