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04011040093 <br /> Waste Tire Survey & Inspection Report Inspection Report.NumberState ■ <br /> CIWM rlei(Now Survey Form - Page 1 11 - 10 7 3 3 8 3 <br /> CIWMB 181(Naw 0004) <br /> Califamia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- () f Imo/ I <br /> Inspection Type.(Fill one) <br /> Site Suffix: / 3 / Si �I / Z - <br /> ®Routine O Re-inspection O Referral O Observation <br /> i <br /> Local "4. <br /> If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP O CIWMB O Complaint O Educational Visit 0 Other <br /> Business orFacInspected By Inspector <br /> Phy al Address <br /> I _ C' u�sf!2 Isla <br /> m TOT U . � <br /> Street !� <br /> Inspection Date r a / O 1 <br /> I - �o� , o� 95-3-30 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> MOPM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i?� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f r l/ ®Active 0 Passenger ( Generator ®Outdoor <br /> GPS Latitude <br /> O O Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> --��—`� 0 Inactive Q Truck <br /> Longitude - I J Q Planned #OTR O 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 O Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer O Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder ®Other <br /> Part B=Inspection of Waste Tire Dealer,Generator,Hauler and-End-Use FacilityENFORC--EMENiTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q EXtenslo <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / IT—] <br /> / <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB. <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NO V or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No violations <br /> Q 0 Other[:: §,� <br /> Comments I�yV(�f <br /> >'m s V Pity cel . �J t� ✓ Ju Y, fi <br /> Inspection FormIncluded:Q, �7 q <br /> SI-t�- /3a / <br /> Comments Included:Q <br /> Busine Rep's Signature Phone Number .Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: 62081 <br /> � EXa �AP ;L. �� 1 23 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy LEA -■ <br />