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os�as©400as <br /> ue- <br /> Waste Tire Survey & Inspection Report Inspection Report Number . ■ <br /> Statao 181(ornla Survey Form - Page 1 17 - 4 0 8 7 0 1 <br /> CIwMe 181(New nage) Y g <br /> Cailfomla Integrated Waste Management Board `� <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 3 7 l / 1-5-1 /-7 1 .9 - Is Routine Q Re-inspection Q Referral Q Observation <br /> Local (� L� rl If Referral,choose referral type(Fill one) <br /> Identifier: !+�_ 4 � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �\ Inspected By :nspector <br /> j 7T�7�rjllll / J I �p 41��A <br /> Physical Address /f(j ��,�^��mv <br /> oosV �_ <br /> Street <br /> Inspection Date <br /> 9s33oI <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM m O PM <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); TZ <br /> _ 0 Active Q Passenger 19 Generator Q Outdoor <br /> �O Q Closed Q Altered <br /> i <br /> GPS Latitude � Q Hauler •Indoor <br /> Q Inactive •Truck <br /> j I v <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 •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 Facility ENFORC,EMEN STATUS <br /> UV 1111kAllill!,HAULING.AND.MANIF1i kREQUIREMENTS <br /> Notice Of Violation Q Extension <br /> Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-omplian¢e Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date [oil <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 FXV <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/C-IWMB 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 C-ompliance No Violations <br /> Q Q Other: §• <br /> Comments �A10'Ko�.2 v�� .f/�_1 Kms/ lltG� n/�__✓ �� w�J /"/ <br /> �� T z I'�•� / ""'"lr� �;'/^C' t�S��G.G?K�.�7'l'-(CJ"� I�LC�'vry t.[�n� �'�'jy'I/��W. <br /> Inspection Form Included:Q P <br /> Comments Included: _�o2csf_�SPSSB� /rGbo -, 0 3j <br /> usiness Rep's Signature. Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIaIMIP[LIE) 111,2131 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />