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�7'si�u�#01�5 <br /> Waste Tire Survey& Inspection Report. :InspectionReport'Number <br /> State of California <br /> CIWMB 181(New 04!04) Survey-Form -� Page 1 18 . 1- Q 7 34 7 2 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business ProfileInspection'Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: �. 3 3 ®Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SaM1'rwCa�ti✓t+ Q'CHP QCIWMB `Q Complaint <br /> 11 Q Educational Visit..Q Other <br /> Business or Facility Name.— <br /> Inspected By Inspector <br /> th <br /> Physical Address <br /> L� -ate <br /> Street <br /> •�+ �, A Inspection Date <br /> V1 9S-zd3 I Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title m' Ift AM AM <br /> O PM m•F O PM <br /> Operational Status Sire Type Business:Role Storage Type •. <br /> Tire Count(Whole/PTE) ' ; 1 I l T {FiII one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator ®Outdoor <br /> 1 I l D Q Closed Q Altered <br /> GPS Latitude L I I II T <br /> Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck' <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) ; L <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ' Q Government Q Retreader p 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 ENFORC-EMENT 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 / IE <br /> / m <br /> O 014 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 F110IWMB 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 �.,,. ,,(. <br /> / � ����LfLI�'►b�✓ —��ra�1C1�.��1�`aAyx i -,r C(.$i- NO -wcw- uket Clc� s1�L <br /> R --1-'�L--7`o-'r-r -- r �E�M�G:+�.�..=�A1�PYJt�V i t-',d 1.I�2C1y� <br /> —rl c�� Navy ►M 11AfK^ 9 Kt 14ptrat rAzd— <br /> oi� st�c , j.)o vrrll.ct�'�urtt• + <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business s Signature .Phone.Number . spSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EIX Ar.M P 62081;� 1 2 3 <br /> ■ White.Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />