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VIJZ �l�i�4J� <br /> ■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> era. <br /> °° staramcaidomia Survey Form - Page 1 11 - 1 0 7 3 5 4 9 <br /> CIWMB 181(New..g, <br /> Caliromia Integrated Waste Management Board - <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( / 1 17 Inspection Type (Fill one) <br /> Site sufBX: 131 - ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: _�0. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> bs , r / <br /> Phys cal - dress � <br /> 202-0 N <br /> street r o <br /> �,y,� d/ Inspection Date <br /> City �r Q LA State ZIP�Code Time In J—] Time Out <br /> Business Rep Title <br /> 0A m;m 0A <br /> c 0 PM IS PM <br /> Operational Status Tire Type Business Role. Storage Type <br /> T' Operational <br /> one only) apply) ( apply) ( <br /> Tire Count(Whole/PTE) � � /��y/ ( Y} (Fill all that a I Fill all that a fill all that apply) <br /> 6 Active Q Passenger Generator ®Outdoor, <br /> OQ Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> �I Q Inactive Q Truck <br /> Longitude _ -1 I f�O Q Planned OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) �1 <br /> Q New Tire Dealer O.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 •Other <br /> Lln�w�tcS'.►!w� I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V VAUHAULING AND MANIFEST 0IIIIIIIIIIIIIII <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 (Required for NOV or EX fJ <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/IS 11111 M BIREnforcement <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 <br /> In Compliance - No Violations <br /> Q Q Other. §, <br /> Comments <br /> ry�t M� ,mac ,'-'A p1 xertaktel� <br /> _0-* - Sea 43�0]CUx3.c4-nl WitI'[ o Q CA, 'fir a `� t to Sal a" <br /> —t-YMrC�`te r +,p-ftci�T.r� td�rtl>c �C�.—NO V.tf�� -- <br /> Inspection Form Included:Q to <br /> Comments Included:Qx � T64`06 Z3 <br /> Business Rep's.Signature Phone , mber hnspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK. Correct: Incorrect: 62081 <br /> E }fAMPLE' 1.123 <br /> ■ - White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> t <br />