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e' Waste Tire Su y & Inspection Report Owspection Report Number <br /> ® <br /> 7 <br /> State of California 10 <br /> • q CIWMB181(New 04104) Survey Form - Page 1 �._ -- ! <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey ? <br /> Business Profile Inspection Details <br /> TPID- Fr� '' Inspection Type (Fill one) <br /> Site Suffix: i � i 0 Routine 0 Re-inspection 0 Referral Observation <br /> Local r i If Referral,choose referral type(Fill one) <br /> t i'\ '� { t f� (' CHP CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: D <br /> Business or Facility Name { Inspected By Inspector <br /> Physical Address <br /> i <br /> / / / <br /> Street ,'� l �_ r Inspection DateLoL"/ <br /> L F--,,---,]L 7-- j <br /> I:;i{ ' <br /> CdState ZIP Comic i Time In Time Out <br /> Y Q AM Q AM <br /> Business Rep Title <br /> Q PM Q PM <br /> - — —I"-- -------_j Operational Status Tire Type Business Role Storage Type <br /> mm <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> Tire Count(Whole/PTE) 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> — 10 ® Closed 0 Altered <br /> PS Latitude <br /> G , Q Hauler 0 Indoor <br /> !!! O 0 Inactive 0 Trtick <br /> C)Ti End Use Container <br /> Longitude - (� Planned <br /> � Business Type (Fill all that:apply) <br /> 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other _ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> V A 1 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 m m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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: --- -- -- — - — <br /> Comments �:, r r f �� ?✓( ( /G �.r r.i �; ,� <br /> } + ._�t t, i��`,� .. ( ` I'? �; �Ytt'} , 4 (�►'/y� R>i'J(k` �1� k F f f t /' - <br /> 1 i•( S t.i ('.; ,1 t :%It 1.�(1 j 1 '- !f(�t , (t /i t '.tel Y, i (�.- f ( l _? - <br /> f Ica _ <br /> Inspection Form Included: 0: <br /> Comments Included: 0Ing Inspector's"Signature Phone Number <br /> Business Rep's Signature Phone Number �p <br /> ,r 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �0 A "�I ; A s 1 , s i <br /> _ ® ■ <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />