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10160040013 <br /> Waste Tire Survey & Inspection Report Inspection Report Number. ■ <br /> State of Califomia <br /> CIWMB 181(New Survey Form - Page 1 - I 1 - 114119 4 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �ii Inspection Type (Fill one) <br /> 1-7 Site Suffix: I l 1510 <br /> 6 I • Routine 0 Re-inspection 0 Referral- 0 Observation <br /> Local t�(7l/� If Referral,choose referral type(Fill one) <br /> Identifier: �t,)I 1 0 CHP 0 CIWMB Q.Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address V ( 101" /�,,(byI(�� <br /> _x- <br /> Street <br /> Inspection Date <br /> city �o Q5366 <br /> State Z/P Code Time In Time Out <br /> Business Rep Title _)�Q a AMi O C n AM <br /> 0 <br /> O PM l v ``7 QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' ' 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ Active ® Passenger ®Generator ® Outdoor <br /> GPS Latitude I O tib Closed 0 Altered <br /> 0 Hauler 0 Indoor, <br /> O 0 Inactive (�Truck <br /> Longitude - 0 End-Use 0 Container <br /> g � Planned - 0 OTR ' <br /> Business Type (Fill all thatapply) <br /> 0 New.Tire Dealer 0 Auto Repair 0 Trucking-Fleet Q.Govemment- 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 ENFORCEMENMSTATUS <br /> .. _ ,� a� xKs -.� ��,h�. <,. ,,.. �.,,�::; �•���.�� �€,�,�'�u<do ,,...d"" <br /> Y A" HAULINGAND MANIFESEQUIREMENTS �� � <br /> �tiQ Extension - <br /> 0 0 PRC§42951.-Waste Tire Hauler Registration and Transport of Tires a" **� <br /> PRC 42953-Contracts with Re X14a. a� x <br /> Q Registered Waste Tire Haulers.§ 9 Deailline .� � aw- <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14.CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB " : _ ;1 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days "�' (ReqWedfor•NOV onEJX+� T)gger; <br /> .KYp Vf$`i.BF.AF,a .�',� �.d�'y' �%4�SPi • <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years r• r- ern# ! �kr " <br /> �eYGlj�Jl eA���3EA}i#!.. <br /> 0 .0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers OReferrced/i,CIWMBEnforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> wa.W�+Ai's1KiMa4me�aq .+��.ta arse- [n,. ,ax�.a art4.�'g <br /> 0 0 14 CCR§18462-.Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> 0 0 ®,,�In��Co�mpllan�ce��. N�o�r�Violations �, <br /> Comments � 1„ � ��5..j_�^ �n <br /> I <br /> Inspection FormIncluded: <br /> Comments Included: <br /> AusinssePSi.gn,ture .. Phone Number �� or' ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACCorr'ct� correct ( a X A�hA P L 1 2 3 <br /> K <br /> �•• y� , ' . ..' :. <br /> White Copy; IWM Yellow Copy.Operator Pink Copy:LEA ■ <br />