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. <br /> Waste Tire Su :y & Inspection Repor Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 7 • i Q 1 $ <br /> California Integratedste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />+ TPID- Inspection/'� l` / 101 - 5)T ) <br /> Inspection Type (Fill one) <br /> Site Suffix: 1 f 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � r - If Referral,choose referral type(Fill one) <br /> Identifier: ,�t tuA (�(/�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ielE ji( �'t Trt�cj�tr� L i 2 _ <br /> Physical Address /J <br /> Street <br /> C Inspection Date <br /> �U Y �_ I <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title • I QPM O: m QPM <br /> O <br /> 44 r r W <br /> I lJ G t1-f DAh .. .k/tn/�t. .r/�,. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire C11 ount(Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger ® Generator 0 Outdoor <br /> Latitude <br /> r <br /> 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - FTI0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 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. 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 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: §Comments'-1 IV , - ,,.r (� y y r (l �`1 <br /> C [ ( c -1 f <br /> �tMai cf <br />+ f <br /> �Ti((_ y,o,kj �(c) y' �, e d <br /> pection Form Included:-o' <br /> �!-- <br /> Comments Included: ---- <br /> --- - - <br /> Business Rep's Signature Phone Number Inspector'kSignature _ — Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E t_ A MI P I L I El I � � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />