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Waste Tire Su0ey & Inspection Reporo Inspection Report Number <br /> State allSurvey Form - Page 1 - <br /> CWMB1 (New <br /> IWMB 181(New 04/04) <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile nspection Details . T <br /> TPID- j - ( Inspection Type (Fill one) <br /> Site Suffix: f I-/ <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- ) If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name • Inspected By Inspector <br /> LPhysical Address 6, 1 !­d <br /> 11 <br /> � J,. J <br /> Sfreett ry) f /� Inspection Date <br /> Cit - ,' , State ZIP Code Time In Time Out <br /> CBusiness Rep Title 0 AM j� 0 AM 0 PM lJ 3 0 PM <br /> VUr14'/ f <br /> Operational Status Tire Type Business Role orage Type <br /> (Fill <br /> Tire Count (WholelPone on <br /> TE (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> / G1 <br /> ® Active 0 Passenger (])Generator 0 Outdoor <br /> FF10 <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR End Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair ® 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 STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 g 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ' <br /> <_ i , , : 1t, ; ,� I�. . I{'c� - t�,l_ i�:rcfLf {' <br /> =t� turk I.. - i t � ; 1 t rl C� f�LirK �, �! }�rtytd�0ff � c+Y.�:( tt/F <�✓✓I cc <br /> li 4 1' 1.� i �� , Tfu(ks 000l 1y-o o1-e SVo"J CA t% <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E; A .041 p I L I El 11 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />