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Waste Tire Sufty & Inspection Reports Inspection Report Number <br /> State of California <br /> .r CIWMB 181(New 04/o4) Survey Form - Page 1 1 - 1 01 0 5 0 2 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile i A Inspection Details - - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ' 3I 1 1 l S_ - I 0I ! I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: �t;r, C1(A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I Cv U� v\l e L(x: -e r�i Sl I <br /> Street r, <br /> Q 40 <br /> /!, I Inspection Date <br /> ` C-A 9!50 1 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> _J •� /'^'JV %} �i r OPM I 0PM <br /> LTJ / I I V 1 i s <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WhoMle/PT (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PT <br /> ® Active Q Passenger (3 Generator Q Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude I /� #j Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Con finer <br /> Business Type (Fill all �appy) 1116 <br /> Q New Tire Dealer Q Auto Repair 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 l <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STA"i'US " �h <br /> V A I HAULING Awl) MAiiun'=E a'u Ftli:t;UIkLMENTS <br /> Q Q - Q Notice Of Violation Q Extension <br /> 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV 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 Q Referred/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 Q In Compliance - No Violations <br /> Q Q Other: § 1 f <br /> Comments .,7 { - -` / r. <br /> 1 lI" 4 Y (j se� T1,r k 0,- 7'1 f(' 0,f ' p �r✓5 (�,J( �' -e d q 0 � ) j 1� L ;! <br /> plot d OW ,k, r hL,4 . j`, rt <br /> 7` � t,�.t � �:1 S r �" �CtrGt1Iv �_% jc� its,; <br /> Inspection Form Inclu ed: <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X XI A MI p I L I EI -I g 12 131 62081 <br /> White Copy CP.VAIG Yello"n t'�,;y O: Pink Copy:LEA <br />