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A,. <br /> Waste Tire Su "'& Ins ection Re or ection Report Number ■ <br /> State BCalifornia Survey Form - Page 1 4 - 10 13 0 � 8 <br /> CIWMB 181(New 04/04) <br /> I <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Deta <br /> Site - — � LV Inspection Type (Fill one) <br /> Site Suffix: C I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ( Inspected By Inspector <br /> ` -- <br /> / <br /> Physical Address(i 1 ,.t J r �1 L'�. ✓i <br /> i <br /> Street N CA <br /> Inspection Date Tx- <br /> L <br /> -' <br /> l 0 f,� I <br /> 101 D <br /> City State ZIP Code Time In Time Out _ <br /> Business Rep Title Q AM � Q AM <br /> s <br /> O PM O P M <br /> „ . Operational Status Tire Type Business Role Storage Type <br /> �I <br /> y, (Fill one only) (Fill all that apply, (Fill all that apply) (Fill all that apply) <br /> rpr� rount y� f9�o1elPTE) � ��� IN <br /> ® Active 0 Passenger 0 Generator ( )Dutdoor <br /> — <br /> 0 O Closed <br /> Latitude 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> M__ T D Inactive 0 Truck <br /> Longitude Planned O OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber 11 j <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension tt <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 I PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i 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 0 In Compliance No Violations <br /> 0 0 Other: § _ <br /> Comments f <br /> l�( <br /> �� � ter`:�(• ( 1 le � 1 _ LL�r >� �:t 1 I �. l: � <br /> j <br /> r f_0ri- tt t�r" 1�� i' f ,:"( l' cA.W?._ ?� U t.�' <br /> a y-.I oy 4� �{�' �.{.I'i (3( f �C✓ "it t L' <br /> ') <br /> Inspection Form Included: DII <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature PhoneNumber <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X F <I A 14 1 2 w" <br /> 62081 <br /> i , White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />