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• <br />0 <br />€o Waste Tire.Survey & Inspection Report .. Inspections Po �1umb°er � <br />State of California <br />CIWMB181(Ne 04104)Survey Form -Page 1. 19- 10 7 9 10, 8 <br />California Integrated Waste Management Board <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -Inspection <br />Site Suffix: <br />62081 <br />® <br />■ <br />Pink Copy. LEA <br />Z <br />[_7- <br />Inspection Type (Fill one) <br />l <br />O <br />0 Routine O Re -inspection O Referral O Observation <br />Local <br />Identifier: <br />Sam To Q %n C o untyy <br />l J <br />If Referral, choose referral type (Fill one) . . <br />O CHP O CIWMB O Complaint O Educational Visit .O Other <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address I <br />3 1 Q <br />LK�IS}t.QQ_L.UCA.� <br />L_11 <br />Street <br />_ <br />G <br />Inspection Date � 3 � ` ` / � 8 <br />L Lad -1 CA 4 5Zy0 1 <br />Time In Time Out <br />AM 0 AM <br />City State ZIP Code <br />Business Rep Title <br />m' m 00 PM m' m 0 PM <br />__T <br />Tire Count (Whole/PTE) I <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill. all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />0 Active <br />O Closed <br />O Passenger <br />O Altered <br />0 Generator <br />O Hauler <br />0 Outdoor <br />O Indoor <br />Latitude <br />GPS <br />I �O. <br />Longitude - I <br />1 <br />rO <br />I IO <br />Inactive <br />O Planned <br />• Truck <br />O OTR <br />O End -Use <br />O Container <br />Business Type (Fill all that apply) - <br />O New Tire Dealer O Auto Repair 0 Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br />O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br />O Service Station O Hauler O Agriculture O Shredder O Other I I <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS. <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />O Notice Of Violation O Extension <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />OO <br />14 CCR § 18459 - Responsible.Entities Complying with Manifesting Requirements <br />DataED / 11:1 / IE <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O Referred I CIWMB Enforcement <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 In Compliance - No Violations <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />O <br />Other: § <br />Comments, ROu 1Y12 1.[i�Gtl_OiLti�("TO(NI�C�LD d1A5 <br />st>c—-�d�QU Irl ca u—(LQL�CL� <br />r <br />—i•MtJ �Q`Cl�S�V—l1� lel _TO� C(•1MMPfC10� �1Y2-T47��Q,Q� �1f8-G2�'[-CAt�_I(b—�. <br />i -nn. Qn wA, C_&aro_ <br />_or os�Qs— co.a�zm via'te <br />Inspection Form Included: O _ (209 <br />Comments Included. <br />siness l s Signature Phone Number I tor's Signatu a Phone Number <br />. <br />INSTRUCTIONS ON BACK orre t:49' Incorrect: 7j <br />While opy: CIW Yellow Copy: Operator <br />X A M P L E I '2 3 <br />62081 <br />® <br />■ <br />Pink Copy. LEA <br />