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I <br /> 0921004.0243 <br /> �eaa_ <br /> Waste Tire Survey &.Inspection Report Inspection Report Number <br /> as State of California <br /> CIWMB181(New"04) Survey Form - Page 1 I1. - 1088064 i <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR.BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- [k]31 <br /> r � JT 4Inspection Type (Fill one) <br /> Site Suffix: \1J� �3 CI:11 . <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: YlAC�IJ COC/I�L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> ��d' . Corn�puv_iy—► 3 c� _ ` Q <br /> Physical Ad ress J f LSA Yh1lG_`J <br /> I <br /> �. <br /> Street � W'CJUj Inspection Date W / F� , I / 101 <br /> [y <br /> CitL y` -Tate Z.'?Cc do Time In Time IOut! <br /> Business Rep TitlePM <br /> � J O AM {� �—' Q AM <br /> GPMj I l I �/� <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill oneonly) -(Fill-all that apply) <br /> (Fill all that apply) "(Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> r f ®.Active OP assenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> • _ _.__.__ _ ___O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V = HAULING AND MANIFEST REQUIREMENTS Q Noticlolation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 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 Complying with Manifesting Requirements Date LE / El / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB- <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FX7) <br /> Q. Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!C-IWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No 1/iolations <br /> Q Q Other: §, <br /> Comments RQ,I ll'1-__TyL'.0ee, cm A <br /> ,moo -( &1 <br /> Inspection Form Included: Q <br /> Comments Included:Q , <br /> Business Rep's Signature Phone Number Insp c or's Nna4re Phone Number <br /> INSTRUCTIONS ON BACK Co ect: correct: MXjAjAhjPjL1E1 1112131 <br /> 62081 <br /> White C y.CIW Yellow Copy.Operator Pink Copy.LEA <br />