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® _ Waste Tire SL. . ey & Inspection Repor', Inspection Report Number <br /> i7•i;7 State of California I 1) /•t /t /} <br /> CIWMB181(New 0410m4) Survey Form - Page 1 ► o - G 0 n 5 t7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix: 2 ) * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: S �r„y� )v «�� t� �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> �u.y �jtom! hiPh�Cical Address — t L> \ V L <br /> 7 Y V LL� <br /> Inspection Date <br /> .��(•t�Lam] � f� � �� l <br /> l d Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> 'l -Z 3, V ® PM ® PM <br /> t as 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 /> ® Active ® Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ® 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 J <br /> - _. . <br /> V A 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. 7 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 (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 (Required for NOV orEX1) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3yar-- <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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments "Y'LVA <br /> G��^� V `lam V t�L- ,-— U0 L­<;L. ` t�-S <br /> \ 1- <br /> p t t,I Vt.t u P E>-� w �l J•� Lo_ Vi 7 �-'t-t 'X, ) L v 7 l^'t`g C t"4-1-- <br /> LL cr- - <br /> Lt 4-� C_ L <br /> Inspection Form Included: <br /> Comments Included: 0 3 Z'0 ��J <br /> Business Rep's Signature Phone Number Alinpector's Sig ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,� E X A MI P L �E 1 2 62081 <br /> White Copy CIWMB Ye'cri Copy Operator Pink Copy.LEA <br />