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0$G�QUg0i97 <br /> 1 „- Waste Tire Survey.& Inspection Report Inspection Report Number � <br /> CrWMr181(emia Survey Form Page 1 17 - 1 0 7 3 5 9 5 <br /> CIWMB 181(New nage <br /> Cali(omia Integrated Waste Management board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> { Inspection Type (Fill one) <br /> Site Suffix:uz: 0 4 � � � ®Rouutine Q Re-inspection Q Referral- Q Observation <br /> Local H Referral;choose referral type(Fill one) <br /> Identifier. -Vo C. ._..y� Car�a.� Q CHP Q.CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . <br /> _ ' a Inspected By Inspector it <br /> I I ir_<a_G,v-el_wlne�l_O1.�t la# q <br /> Physical Address 3 / - LAwawt p <br /> Street <br /> Lt <br /> Inspection Date I Z O 6 O <br /> I S+v -Ie <br /> City State ZIP Code Time In Time Out <br /> Business Rep p Title O AM O AM <br /> L—_ c<.o�A'SWY •PM m m ®PM <br /> Operational Status Tire Type Business Role Storage Type-. <br /> 1 i j 1 I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 'Z <br /> i I I 010 <br /> . 0 Active ®Passenger ®Generator Q 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 *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 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 <br /> Q Notice Of Violation <br /> Q Q Q Extension <br /> 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 <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 ( squired for NOV or FXT) <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 Co p I ce - No Violations <br /> Q 10 1 Other: §, <br /> Comments <br /> . —_ _;rsp.«.1�•.��- t'►�._s �r,t��„ts,C-� ��.'llus Ti,x <br /> CdYJ.f'Zt12t.W <br /> Inspection Form Included:Q <br /> `7rb P—Ob S' <br /> Comments Included:Q <br /> Bust ss Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i 1EX A M P L E' Ifl2131 62081 <br /> . White Copy:CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I _ <br />