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to <br /> Waste Tire Survey & Inspection Report Inspection Report NumberSlate ■ <br /> rr <br /> CRUMB181INCalifornta Survey Form - Page 1 12 • 1 0 1 3 71 <br /> CMlMe 181(New 04104) <br /> Catlfomla Integrated Waste Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / 3 Q ? - © ` ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �,w ..r- _ If Referral,choose referral type(Fill one) <br /> Identifier: �` `..JI O Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Eec qi,�(Ylt4 <br /> Physical Address <br /> Li3U) N euJ4on PC] <br /> CSix, Inspection Date G ( / <br /> Uri <br /> Time In Time Out <br /> Business Rep Title ! O AM O AM <br /> inwv cwwkff_ 9Z' <br /> v IRh _ O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> t r @ Active Q Passenger ®Generator 0 Outdoor <br /> GPS Latitude <br /> O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O I Q Inactive Q Truck <br /> Longitude - Q Planned ®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 �Hea v y <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 F6fti_NIEN fStATUS <br /> � �H>413C.li�ts�>I,IA(�t�liFE3T REtlUIEfEMENTS _ - ._ -^���, <br /> QQ PRC§42951-Waste Tire Hauler Registration and Transport of l res NoticeOf Violation 0 Extension <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 ILI <br /> / [Ij <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB l^ J <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (12 gvhad for NOV w <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred F C(WMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsy In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> J,?, f- I Ye �s &C WNte Ve?S 'f` CTL dad of <br /> ,Ju +,Af 2M� a �'4'i:D _ nilc� �s� ti t�i�- I �y ( {_d,�- Wke <br /> -- <br /> � ( l __ Ii CTL i cvt } N,, v Dlcztrens <br /> Inspection Form Included:Q J , <br /> Comments Included:Q �Vl <br /> sinew Rep's 3lgnalure Phone Number 1 or's ature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK 76 A M P i E 2 3 ® ■ <br /> White Copy:CIWM8 Yellow Copy:Operator Pink Copy.LEA <br /> 0633304.0088 <br />