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08129040957 ■ <br /> err <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> 11 State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 7 - 10 7 2 8 6 1 <br /> California Integrated Waste Management Boats <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I j 1515 11 131 / Inspection Type (Fill one) <br /> Site Suffix: .Routine Q Re-inspection Q Referral Q Observation. <br /> Local �- If Referral,choose referral type(Fill one). <br /> Identifier: Sit,J L/;Agt[4 iii e00A) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> [�9 - l D � i�i baa-nom � <br /> Physical Address <br /> 2501 N r /.tWi� t,J4wl 17/1 I <br /> Street <br /> � !✓4Inspection Date <br /> ft State ZIP ode Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ' <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r' I I r' <br /> •Active 40 Passenger •Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS El IQ•I-�_��0 Q Hauler . Q Indoor <br /> 0 Q Inactive �Truck <br /> Longitude – F FTI,. Q Planned Q OTR O End-Use Container <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder 10 Other Lf1 �NPCRinl� t,1twL <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V IMMA AND MANIFEST REQUIREM6N S <br /> Q Notice Of Violation Q Extension <br /> Q O !PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IE <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Require for NOV or HX7) <br /> O O - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§16461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: § <br /> Comments A/7iivE /iV�DeUf,p1� OYI %17t .�IL�. _I-1�0u4✓!L.)A <br /> �Je�s crc�P of r'�e�n <br /> Lia_.�el.—U r ua a,4 <br /> I� <br /> Inspection Form Included:Q 2� <br /> Comments Included: 4(-e <br /> O sines s�gn.tur.�_ hone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: correct: E X R IM P L E[ 11[213 <br /> ■ While Cop CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />