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�. W.. .,_ <br />ey & Inspection Repor <br />Waste Tire Su� <br />Inspection Report Number <br />StateofSurvey Form -Page 1 - <br />CWMB1 <br />IWMB 181 (New 04/04) <br />California Integrated' Waste Management Board <br />01 <br />Part A- Survey BLUE OR BLACK INK PEN <br />Inspection Details <br />I TPID "� - Inspection Type (Fill one) <br />Site Suffix: , r� , ' 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local f 1 If Referral; choose referral type (Fill one) <br />l� <br />Identifier: <br />a h $1.14 f`t N14 VL1 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name 11 <br />'t af` 0 <br />Inspected By <br />- <br />Inspector <br />( <br />Physical Address <br />I <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />Street <br />S� 1 <br />/ <br />Inspection Date <br />oG <br />� !Ct � r J C / � <br />V >i <br />0 <br />0 <br />city State <br />Business Rep Title <br />T <br />ZIP Code ime In <br />O AM <br />Time Out <br />O AM <br />ovjru r <br />0 <br />0 <br />:1 OPM <br />m' 0 P <br />0 <br />Other: § r <br />Operational Status "Tire Type <br />ge Type <br />Business RoleLRII <br />Tire Count (Whole/PT <br />(Fill one only) (Fill all that apply) <br />(Fill all that apply)ll that apply) <br />0 Active 0 Passenger <br />Q Generatorutdoo <br />Latitude <br />O (9 Closed 0 AlteredGPS <br />0 Haulerdoo <br />0 Inactive Q Truck <br />Longitude — <br />0 Planned OTR <br />0 End -Use <br />Business Type (Fill alf" <br />71 <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler <br />0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <br />0 Shredder (4 Other e 1;,. <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />11 q HAULING AND MANIFEST REQUIREMENTS <br />0 Notice Of Violation 0 Extension <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § r <br />Compliance Deadline <br />Date m/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments <br />Dwner n ri Q� r r � ey� tiro s w�i{i�r �� Qrr'� a <��y� ry <br />100 ILI s (eveoved -t C'7L5 ✓���y? U t <br />' or"r/? /�) Y`:v tri t ;`i U J �.'ii S CLIC NO D/' VJ _(AP <br />spection Form Included: <br />Comments Included: 0 - - <br />r Business Rep's Signature Phone Number Inspector's Signature tl Phone Number <br />X `j / ___ I e a I P I 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: �/ E X f+, ,,, P 2 3 <br />v White Copy: CIWMB Yellow Copy i )[� , ilor Pink Copy: LEA <br />