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■ Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> r„ <br /> CFWM ofCaliforniaSurvey Form - Page 1 1 4 - 0 1 3 5 0 8 <br /> CeNMe 181(Naw 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survev - - _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• /� q Inspection Type (Fill one) <br /> Site Suffix: p? Y 7 3 7 0 1*Routine Q Re-inspection Q Referral Q Observation <br /> Local (' If Referral,choose referral type(Fill one) <br /> Identifier: JQ..1 �Olu. j7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !!ff — - <br /> A �r� Inspected BY Inspector <br /> _* /S <br /> Physical Ad-dress 3 9 — / fi,go <br /> 3 702 4E, ka—eu.,-r- Z <br /> fl4^ C, 9 Inspection Date O / 3 O / <br /> Time In Time Out <br /> Business Rep Title � � 0 � :PM j � � � 0 AM <br /> (/ •PM <br /> Operational Status Tire Type I Business Role Storage Type <br /> FTire Count(Whole/PTE) <br /> (Fill one only) Fill all that apply) (FII all that apply) (Fill all that apply <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q InactiveQ Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q 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 Facilityhlt=OiZL�tVINT'STAtUS <br /> �� i�+1iQf112EMENTS {?Notice Of ViotatianQ Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and 1 ransport of I ires , <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cornpiiance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle _ <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate r. <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB L� <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (k00uked for N0V or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!CIWMB Enforcement 1 <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 Q Other: § <br /> Comments <br /> ./l/tu• S,�orc ae�lcs°r � �t��f- �,3.Za3 � ��-�- � . <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK E^ j Ak P L 2 3 62081 <br /> ® ■ <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br /> 0633304.0071 <br />