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�Sl23�90753 <br /> Waste Tire Survey & Inspection Report Inspection Report Number - <br /> CFWM I. 101(New Survey Form - Page 1 - 13 - 10 7 9 1 6 8 <br /> CIWMa 181(New 04104) <br /> calnomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O � S ��� - O , Inspection Type (Fill one) <br /> Site suffix:. I I 7 '� I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one). <br /> Identifier: 5a�/ �pa i w) �-oJN�f�,r Q CHP . Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'f Inspected By Inspector <br /> Physics Address I 1 1—Mot <br /> i <br /> Street <br /> Inspection Date [1 <br /> 952 yi <br /> C1 y �r State ZIP Code Tlme In Time Out <br /> Business Rep Title 0AM 0 AM <br /> F 1 10 PM LLI: 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> j f <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> r I r Active Passenger ®Generator O.Outdoor <br /> Latitude I I Q Closed Q Altered <br /> GP$ Q Hauler Q Indoor. <br /> ! �0 Q Inactive S Truck <br /> Longitude - FT- --I I, TT I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC--EMENTSTATUS <br /> H <br /> V I A AULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-RegistrationlDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 -- - ._....... <br /> 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 I 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 1 Q 1 Other: § <br /> Comments <br /> Inspection Form Included: O _ n <br /> Comments Included: �sQ yv.�.��� J Phone <br /> ne N 9 <br /> Q Business Rep's Signat8re Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C►orreet:� Incorrect: I= X A M P 'L E 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />