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Waste Tire SL*ey & Inspection Repore Inspection Report Number <br /> Stateof California j/J{ <br /> CIWMB181(New04/04) Survey Form - Page 1 1 10 13 7 4 f-jJ <br /> California Integrated Waste Management Board -- ------ --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ _ Inspection Type (Fill one) <br /> Site Suffix: ` { , 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / I If Referral,choose referral type(Fill one) <br /> Identifier: I �.'�( C/i,4 lV t t ,4 YL L 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name f 3 G Inspected By 0 Inspector <br /> Physical Address L) <br /> Street t Inspection Date <br /> City State ZIP( Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> r r <br /> 0P � ' � 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 'Tire Count (Whole/PTE` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> JIIIIIIIIIIIIIIIM (4 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0Closed 0 Altered <br /> GPS <br /> Latitude m . <br /> �I <br /> ITIO 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude — 0 Planned 0 OTR 0 End-Use Container <br /> WONew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 V i-'f,I.0 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A !,HAULING AND MANIFEST REQUIREMENTS <br /> - 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 m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / LSM <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 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 l 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: § o <br /> Commentsf r 1 <br /> z �l,'lllrftr ,f ( f Ilr( �►'',� r �rir/ L•.)t/6..� <br /> `(i'.`l � Ir ` ir'{ l ��r � f✓ `� (l�h1V11 r / /011 � .fii(1Y'(� JC'�M�l: I9�i ii ✓rl�� (i f li <br /> �t; �lt Fr��,� 1( ! ii✓ � ;r ' rt�a' r 1�✓F i� (:��Jr{ t' I , rlc k) <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number inspector's Signature Phone.Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X EXE ,� ,j P Z <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />