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08182f14�223 <br /> Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> �eaa_ <br /> State of California <br /> CIWMB181(New04l04) Survey Form - Page 1 1 6 - 10 79 3 6 0 <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: I. I 3 $ �Icn I ' K — <br /> I I— Routine QRe-inspection QReferral <br /> Q Observation <br /> Local \ (h If Referral,choose referral type(Fill one) <br /> Identifier: Ski) ��(� W� Q CHP Q CIWMQ Educational Visit <br /> B Q Complaint Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �1►1�S k i Com. T S o.S I . r <br /> Physical Addres <br /> �3 3 J - <br /> � � �io`� <br /> Street � I <br /> Inspection Date <br /> city y�1 State ZIP Code Time In VV Time Out / <br /> Business Rep Title - [�o <br /> 0 PM PM <br /> 0 AM <br /> .G t -- �s t Se"j7 <br /> �OL G�Gt- Operational Status Tire Type . Business Role Storage Type <br /> Tire Count(Whole/PTE) ' ,C (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 101 Passenger O Generator Q Outdoor <br /> Latitude I I I IO Q Closed Q Altered <br /> GPS I Q Hauler Indoor <br /> Q Inactive Q Truck <br /> I o <br /> Longitude — I I 1 I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 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 I <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 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 M / m / 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 EX7) <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 I CIWMB 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 Violations <br /> Q Q1 Other: § <br /> Comments \ ^ <br /> U -�_ t t1g —' <br /> Ne:��.� �i__u, S �o�h��,�, c� �o� —�.-—-.G�1 n -, an�_CV�T(h_aS�► i rt�e�'. <br /> Inspection Form Included: Q 1 <br /> Comments Included: kfureusiness Rep' Phone Number Inspec r s Signature <br /> Ah�one Number <br /> INSTRUCTIONS BACK rect: ncorrect: ( 62081 <br /> EXAMPLE x :23 <br /> White Cop 1112IW Yellow Copy.Operator Pink Copy LFA <br />