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■ <br /> Waste Tire Survey& Inspection Report. Inspection Report Number <br /> Stabof California Survey Form - Page 1 1 9 - 1 0 0 5 3 5 9 <br /> CIWMB 181(New 44/04)mY g <br /> California Integrated Waste Management Board `�' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I - Inspection Type (Fill t �OCT _5 pq 3: 21 <br /> Site Suffix: Q Routine Q Re-inspection Q Re erral 0 Observation <br /> sr,r� ao R r�+r{g cou;�r <br /> Local If Referral,choose referra�ty,�e �gl.j, Y <br /> Identifier: Q CHP Q CIWMdiEAatWVLatnntrtA%jfional Visit 00th,, <br /> Business or Facility Name ( Inspected By Inspector i i <br /> l' r <br /> Physical Address <br /> Streer <br /> Inspection Date .7 / 2 � / M': IL-.�.C,4-0 <br /> City State— ZIP Cod Time In Time <br /> mOut <br /> Business Rep Title C AM0 AM <br /> ®PM n 3�� . © Q o PM <br /> LLL �« Iii <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active ® Passenger a Generator ® Outdoor <br /> � + � C Q Closed Q Altered <br /> GPS Latitude I , Q Hauler Q Indoor <br /> i r - — O Q Inactive 0 Truck <br /> 7-7 Longitude i i I , I i Q Planned Q OTR Q End Use Q Container <br /> tit <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 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 /> r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date J / J / J <br /> 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 EXT) <br /> Q 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 vioiations <br /> Q Q1 Other: § <br /> Comments <br /> '�" ty�St'-� -�?►-e 1�°r-�Ua�s ��� U.�w���"1r'tr� li�..at t�t'-�'�s`�3 <br /> t2GV ti <br /> Inspection Form Included: Q - r _ <br /> Comments Included: C 74—/(2// 4 �� <br /> Business Rep's Signature Phone Number In ect- Signature Phone Number <br /> • �� �-�/ F 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ EXAMPLE 1 Z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />