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-L , Waste Tire Sur & Inspection Report l ispection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 7 - 1 0 0 0 5 8 8 <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: ( l I/) -7161 -7 a 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: err— _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street / c Inspection Date <br /> t <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m ' 0P 0PM <br /> Operational Status Tire Type �� Business Role torage Typ <br /> Tire Count(Whole/PTE) 7 nc— <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that ap` <br /> ® Active 0 Passenge jo Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m . 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR O <br /> End Use Container <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 /> 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 <br /> 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 or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> �^.���//h �!7�c7�ir-, t �Y--�)✓�: S l�c=.STG�_ �1; z --�L1J� — — <br /> rje' IC.t'�I4`74"S <br /> f <br /> Inspection Form Included. 0 <br /> Comments Included: 0 -- - - - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X km i,�. i"I P LIE1 111213; <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i _ _ <br />