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-------- ------ __ -_ ., -...:t- ­­ . �-- 1.- --, --._­ — & - .._. ­_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1143487 <br /> California Integrated Waste Management Board <br /> Part A- Survey- BLUE OR BLACK IN-K P-E N <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l l p2 1 1 Q l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: j Y-\- LA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> or —Na.. — <br /> dis.—ine.. Inspected By Inspector <br /> 0Y'Vk\jef_S.C,� -SLA.)CePiV1C <br /> C <br /> Physical Address - t 0 6n,,, A-,,nt bc <br /> t <br /> b�tN� CA Q5c-)L15 Inspection DateCr <br /> Time In Time Out <br /> Business Rep Title 10 AM 0 AM <br /> 0 PM v A PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> a Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> Longitude 0 0 Inactive ®Truck 0 End-Use 0 container <br /> 0 Planned 0 OTR <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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS 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 /> 0 0 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 (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 114 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 in Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> See, _Cceryneolk <br /> Inspection Form Included: O; <br /> Comments Included: � ____> - - - <br /> ignatu Phone Number <br /> ine -Rep's Signature— Phone Number . . 7 - - - - <br /> 6 081 <br /> INSTRUCTIONS 0 BACK Correct:0 Incorrect: X 1j2 3 <br /> ■ - - - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: <br />