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/O " / _03 <br /> _ f Waste Tire S%ey & Inspection Repo Inspec um er <br /> ��-I Stale of Caldomia <br /> N CIWMB 181(New 04104) Survey Form - Page 1 - b <br /> California Integrated Waste Management Board BLUE OR BLACK INK P E N <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i o 3 Z� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cuv.,-J V�_ �J �"l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address / G\ \ G \ S`t V 1 ��c' O t <br /> U_ Inspection Date � � � �, / L--, <br /> 5 V <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> 1 1 O <br /> Z? O PM 5 WPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> Tire Count (Whole/PTE) <br /> 0 Active ® Passenger # Generator #Outdoor <br /> - _ O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Flee: Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q S nice Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ^ENFORCEMENT STATUS <br /> V A �HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration a-.d Transport of Tires <br /> O it- PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Comp:,rg with Manifesting Requirements Date <br /> O Q 14 CCR§ 18459.1 (a)(b)(c)-The Program ID N.;mber from CIWMB <br /> I (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days J <br /> Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB'Enfor"cementer <br /> 10 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — <br /> Q O 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I ® In.Compliance -'No, Violations <br /> A_) OOther: § t .. <br /> Conimcnts <br /> � o•ti� i�ti� \ �171i��� vw�S �el <br /> p(� L 3 <br /> i - — w•.t .e,,r V-& v.�, . ----- - <br /> Inspection Form Included: Q ( /, <br /> Comments Included. O v 1 /{{ 7 <br /> Bus ness Rep's Signatur Ph a Number I Inspector's Signature Phone Number <br /> -....------_ — ...____ ._.. .. <br /> INSTRUCTIONS ON BA K rcorrect:0 Incorrect_X V j C X A Nt P 1C I 1 � Z 62081 . <br /> . ` Copy Ye!'o.% Ccp•:'Operator Pink Copy LEA YL��' &y <br />