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.............. - ----- --- ------ <br /> . ... ..... . <br /> --- -------- <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> tri State fCalifornia Il - 1143530 <br /> O <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> (22 <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: � A 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> aJIy� L 0 CHP <br /> Business or Facility-Name Inspected By Inspector <br /> PhCoica��Lroess 5 9 C' t 'q t 6, �►ztr��l <br /> Inspection Date <br /> 1"Y"Y.1c Ll CA C) q Time In 0 AM Time Out 0 AM <br /> Business Rep Title 0 PM I Z- Lt 0 PM <br /> z <br /> -7rr--,o dyn tvt�d Tye-t.,hw Type Business Role Storage Type <br /> Operational Status Tire <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 6 Active ® Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GGPS Latitude ® Indoor <br /> 0 0 inactive 0 Truck 0 container <br /> Longitude 0 Planned 0 OTR Q End-Use <br /> Business Type (Fill ail that apply) <br /> New Tire Dealer 0 Auto Repair 0 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 STAT-US <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 <br /> m / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 n Compliance No Violations <br /> .0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: Phone Number I to ig ure Phone Number <br /> _ Business Re ature 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: <br /> -- - ® ■ <br /> M White Copy:COMB Yellow Copy:operator Pink Cop <br />