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os��so�i�ss <br /> Waste.Tire Survey & Inspection Report Inspection Report Number . <br /> s�t°°"°'�°`nIa Surge Form - Pa e 1 1 7 . 10 10 8 6 2 <br /> cIWMa 181(Naw 04!04) Y ('� <br /> Califomia Integrated Waste Management Board `.y <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / ! I I S _ D I Inspection Type (Fill one) <br /> Site Suffix: b 40 Routine. 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: �� C/(lQQcG+-h 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -—" <br /> Inspected By Inspector/ <br /> Physical Address 3 9I IL <br /> Street <br /> "t G�e+r � 9S3 Inspection Date <br /> 36 I <br /> City State ZIP Cade Time In Time Out FFI <br /> Business Rep Title 0 AM0 AM <br /> ��.��L �-r t.T �i �O/GL�c�z.'L i -m_• <br /> 10PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 01 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ���I I t � �i I <br /> =1 40 Active •Passenger 0 Generator 0 Outdoor <br /> ( l u 0 Closed 0 Altered <br /> GPS Latitude m. I I I 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - v 0 Planned 0 OTR 0 End-Use ®Container <br /> Business Type (Fill all that apply) <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 ®Other _014 iVL I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 'kVj;�rHAU.LINGiANU&MANIFESITbREQUtrnclllfctr IS <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. C-ampllance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EX77 <br /> 0 O ---- - — -....-..- -- <br /> 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/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 J?l,�d ZtR ir+nf/X�7S�t +1 �4y aVF ` � La✓�'7� [!/q! �co�ed i f �^oC <br /> Imew k re.*e ove LW W14,-e(/ 14Y,V4 V V."e ire E6%s v�ewe <br /> Gybon /��rc�ee-f�. ­111�-WAAW-4 )4red a.2 v., )e?� caa�/ r4*+ <br /> zl-Pie�°4-1 Vf 43�4d-f/ { <br /> Inspection Form Included:0 O J ( �� / <br /> Comments Included:0 "6-1 �� // / fL�1K,l(LLe �/��_p33�j <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK <br /> 1EIXjAjMIF I' IE I I1 I 2(3 1 62081 <br /> Correct: Incorrect: S �� <br /> . - White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> L - <br />