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rrr <br /> Waste Tire Su0y & Inspection Reporter lnspecti nUeporfNt mberr'State ■ <br /> CIWM 181(NCaliforola Survey Form - Page 1 1 1 1 Q 7 9 1 5 $ <br /> GIWMB 181(New nage <br /> Calliomla Integrated Wacte Management Board <br /> )'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /1 I n I / I Q I /1 O / Inspection Type (Fill one) <br /> Site Suffix: –/ J L J 10 9 JI 7 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f S�}rJ�OA H i�. 11^1 � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V1Inspected By Inspector <br /> i <br /> Physical Address <br /> I /0.4- �O w IAN d <br /> �f <br /> Street/ <br /> I 1-4-Arsi� / w %s3.36 I Inspection Date 3. F75/1 Q g <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m0 AM O AM <br /> m' OPM m'm QPM <br /> Operational Status Tire Type Business Role . Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ; 3'a <br /> I. 0 Active 0 Passenger •Generator 0 Outdoor <br /> jO 0 Closed 0 Altered <br /> GPS Latitude L ,L –1 0 Hauler 0-Indoor <br /> r ---111 rLL_ t ���H0 0 Inactive 0 Truck <br /> Longitude – I I I I I 7— 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) �I� <br /> 0 New 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT_STATUS <br /> V A 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 / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 ®In Compliance - No Violations <br /> 0 0 Other: §, <br /> Comments C..CY7Q�K-t.T�K 'Q7j /C7 �s �U���ja_�a�L �✓� <br /> G��O�L.tFF�••Lf /�tL��-✓iii- G�'j�f��-•—�-1'I[n_rr_OY_r_�I�S �S-s'�o{itS �iE—GUIST_�. <br /> Inspection Form Included:01 <br /> Comments Included:0– <br /> Bu ' ass Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: ( CEJ I I EM AIIMI P I L I E1,, 111'2131 62081 <br /> . While Copy:CIWMB Yellow Copy Operator Pink Copy.LEA �� ■ <br />