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G73� � t�4i)�41 <br /> en. <br /> Waste.Tire Survey & Inspection Report Inspection Report Number <br /> State Stem 181lNewCaliforniSurvey Form - Page 1 1 9 - 1 0 7 3 3 1 7 <br /> CNVMB 181(New Od/04) <br /> callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ��� ^ f Inspection Type (Fill one) <br /> Site Suffix: / (a Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: J -To � Ce Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U <br /> Inspected By Inspector <br /> I Afo er t cayi JAI o fo,' ew IDR <br /> _ F/T�51 <br /> ��may, �,pPhysical Address I Jy 1 r a 6 c <br /> I g�' lel' SfSt I <br /> Street fDh <br /> ^ q o Inspection Date / <br /> City / State Zlp Code Time In Time Out <br /> Business Rep Title [--1—]O AM O AM <br /> ©JAJ J `' 1 m' O PM m O PM <br /> t�Ur-`�`f.�G.�—✓_!_v�-�--fit----- ,n/f�---_� <br /> Operational Status Tire Type Business Role' Storage Type <br /> Tire Count(Whole/PTE)I r I Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v U ®Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS .Latitude �) �.(—---I-� Q Hauler Q Indoor <br /> ( O <br /> Q Inactive Q Truck <br /> Longitude _ - i I I� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill.all that apply) <br /> JJ I <br /> Q New Tire Dealer ®.Auto Repair. Q Trucking Fleet Q Government Q Retreader ®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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 <br /> M / 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 DCT) <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 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: § /` 1 1 <br /> Comments 1LC�jlt� �yf;.S 2 . .S JfC!( 0! t�oLd t.�{ <br /> e Y_es_ r, 0 _J'rt Z)F ,` �� las iPqG�1�Yt/. 7 m5; - *e< ao <br /> } Spm an i G�S�'S a Jt2% 12. <br /> Inspection Form Included:Q 6z <br /> Comments Included:Q �� -tt���all -1�C-Lt1 <br /> Business Rep's Signature Phone Number spe tors 0ature Phone Number <br /> �-,( v <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X((} l�J [EIXI A W P I L I E 1 Z 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />