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= 09091U40144 <br /> %eea- <br /> Waste Tire Survey & Inspection Report Inspection.Report Number <br /> c77 state of CalHornla <br /> Survey Form Page 1 11 - 10 13 5 7 9 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board _ <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 - Q Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Lscm <br /> �(jry�- C�mtf� Q CHP - Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name '`/1 Inspected By Inspector <br /> �L�n�e►^ y1n��it-.c� s � d�b�nc•F I Ln <br /> Physical Address 3 9 - ( / 1 <br /> L�'� <br /> 35l E� f I �oo <br /> CA-- --I Sf <br /> Street <br /> Inspection Date <br /> caul , lJ 1 <br /> City State ZIP Code Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep Title ®PM � ' � � O PM <br /> Acuccus.o T.ztrws d, _ <br /> _l Operational Status Tire Type Business Role Storage Type <br /> 1 ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole(PTE) 1 <br /> _ _I 0 Active Q Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q indoor <br /> O Q Inactive 40 Truck <br /> Longitude - F1_714 <br /> II I, Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Govemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer;Generator,Hauler and End-Use Facility ENFaR_OEMELT 51TATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> Q I Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 . <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or F,C7J <br /> jQ 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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers.or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments /3t <br /> 11 111 t J�-Cyl-ej.Ctat. t`KY�°I`�'' <br /> Inspection Form Included:Q - <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspcct0 s Sig t Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 '2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ■ <br />