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Waste Tire Su <br /> y & Inspection Report• Inspection Report Number <br /> State ClWM f 81(New Survey Form - Page 1 - � Q 3 <br /> „. � CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> 055 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Gti Inspection Type (Fill one) <br /> Site Suffix: J ' 0L' 0111 O Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `— If Referral,choose referral type(Fill one) <br /> Identifier: �� ` r �, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical dress J CLo <br /> 11 :.x2 <br /> Street <br /> T- Inspection Date <br /> 7r c1 V <br /> City State 2/P Coci, Time In Time Out <br /> Business Rep U Title AM 1 OAM <br /> Aif a 0-1 : 1 0 PM _L 0 PM <br /> ViR <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> The Count(1�Vhole/ 'r B) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> m O 0 Closed 0 Altered 0Hauler 0 <br /> Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - - ! I 1 <br /> 0 0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other J)e_(, y (�L <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 / 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 O - - <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I' <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 0 In Compliance - No Violations <br /> 0 0 Other(}y§, r,, p <br /> Comments 'iC.E"iiUf% �(i'1(`� c'i R S f P. ! '�( Ur>l ow It •. E01}('r✓.k � 'tJ{r IVit(' <br /> c� . �� l_-r '( ter lr Ut1Ct;f ' c4et`_.��` c , 4: <br /> JA <br /> Gt(C' `�0 0 ,d (°or��iF+ ��; L ( ��"l �' ` fC�: '✓ 1J , <br /> '��f"T 'r _�l`..n :/� $.,1�1 t �_ � './ }�I' �'• !i�) �`A I'�, :.• n� ('�..(r -��, �' �;t/1 ...�,- � n .l r� � - l r:,t 1":... <br /> Inspection Form Included: 0' <br /> Comments included: 0 <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® "Incorrect: / <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />