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Waste Tire Sur„ay & Inspection Report Inspection Report Number ■ <br /> 9iII State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 I1 - 1144019 <br /> California Integrated Waste Management Board <br /> A- Survey_ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> i PID- t � �l _ Inspection Type (Fill one) <br /> Site Suffix: I J l 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalL�� If Referral,choose referral type(Fill one) <br /> Identifier: , I J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> z✓t'lZL� �CC'.►�vtG� Lc7��C>`�'i?Nt `� _ ) /� �{ Imo, <br /> Physical Address l� 9 l O I �1 ��'�sc, Ale-.CVI b <br /> 3 --3 s , i4")LI qc� ---- -- <br /> Inspection Date Ll ,� l D <br /> tz:�-L�FYI 421 <br /> Time In Time Out <br /> Business Rep Title t I ® AM AM <br /> l 0 PM ' C/ �� O PM <br /> - - - - - - - --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered /V 'A IV14 <br /> GPS Latitude /t//� Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair 0-Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> FO <br /> Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 A In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments IyIJlO -�tb�'t V Anil C%r� k.1© y�bltl.`f�72�✓zS tT/ AWej 04- <br /> &1(k <br /> L&1(k a,-� �OCGt 7�7�Y! 4-)eAkm <br /> \j <br /> i,...pection Form Included: QI'i <br /> Comments Included: Q -- ---- ----a---- — Y68' �7 <br /> Business Rep's Signature Phone Number Ins ect s Sign re Phone Number <br /> ---- <br /> . _ � 62081 <br /> INSTRUCTIONS ON BACK Correct:' Incorrect: ( �J E X �4 L 112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />