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FOG. <br /> Waste Tire Survey & Inspection Report Inspectio'�p9Nh.rPtJJ <br /> it CfWMstate 181(Califomla Survey Form - Page 1 1 5 1 Q 7 9 5 Q 0 <br /> CnvMB 181 stew 04/04) <br /> agey g <br /> Califomla Integrated Waste Management Board ) `�- <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - f Inspection Type (Fill one) <br /> Site Suffix: 13 3 Z ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:IdentiTic ;1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit.0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> 3 <br /> Physical Address <br /> Street <br /> Inspection Date <br /> - ----- - - - 53�G <br /> City State -ZIP Code Time In C� Time <br /> mOut <br /> Business Rep Title 0 AM <br /> [1] 0 PM o PM <br /> Operational Status Tire Type Business Role Storage Type - <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> - - 0 0 Closed 0 Altered <br /> Gps Latitude i 0 Hauler 0 Indoor <br /> L. 0 Inactive 0 Truck <br /> Longitude I 0 <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> i <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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 00 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-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT)- <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 0 In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments i <br /> +-�,¢,:-t;.tr.r—ts_►�r—C�___-btcs�cku.,,,cca�oc`�4u-lc�_�t�.c.a,os�at—t a/�1Ly <br /> Inspection Form Included:0 <br /> Comments Included:Q — - - - <br /> Business Rep's Signature Phone Number nspector's Signa Ve Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: (� �j E X A M P L E Z '2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />