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J <br />-; Waste Tire Sur*y & Inspection Report inspection. Report Number <br />■ PCB State of California ■ <br />CIWMB181(New04/04). Survey Form - Page 1� 1 2 1 Q 7 3 4 2 61 <br />California Integrated Waste Management Board <br />Fart A - ziurvey bLUL UK LiLAL;K INK NLN <br />Business Profile Inspection Details <br />TPID - - � Inspection Type (Fill one) <br />Site Suffix: r ! Lt { �' / Q Routine 0 Re -inspection 0 Referral. 0 Observation <br />-- _ <br />Local- -- f �- - - I - - -If Referral, -choose referral type (Fill one) - <br />Identifier. '};4 t" (. ` ` ' ! ► , 0 CHP 0 CIWMB - 0 Complaint O Educational Visit 0 Other. <br />Business or Facility Name } t Inspected By Inspector <br />I(`t <br />_ ./ 0 i-! i �i V`"le <br />Physical Address <br />Street 1 <br />/ . 9 I Inspection Date <br />Business Rep Title <br />i, kf, , <br />ITire Count (Whole/PTE) 1:1 f I G <br />GpS Latitude <br />Longitude - <br />^Business Type (Fill all that apply) <br />0 New Tire Dealer <br />0 Auto Repair <br />0 Used Tire Dealer <br />0 Auto Body <br />0 Service Station <br />0 Hauler <br />0 Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />Time In 0 AM Time Out 0 AM <br />�m0PM �rm OPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q Active <br />Passenger <br />(D Generator. <br />Outdoor <br />0 Closed <br />0 Altered <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />0 <br />0 <br />0 Planned <br />0 OTR0, <br />End -Use <br />0 Container <br />Government <br />0 Collection <br />0 Shredder <br />Retreader 0 Dismantler 0 Tire Derived <br />0 Crumb Rubber <br />OtherIt✓ltil/1�1.� 1w,(�"� <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use. Facility <br />V j <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.17 Tire Program ID Number from CIWMB - <br />0 <br />0" <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators. <br />0 <br />Q <br />Other: § <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments <br />h`U I-tf /r Lt / i t �� ; t � 'lit. , ! i �-+ < � ��!t �� ��t ' r 1 � / .. � � 1;� ✓ F `_� /"� hG �: r � �'�; (� <br />lu► i (: fc✓r) 1 `� t�f,i�.rtf<l t. {� rt,, . j 1: d f <br />�114(^1lr1t0C ✓Jl i'7 M: f t.✓I'ti- 1� AI"r'»tl./i t' Aki 1/1111/7 1l0)")`. nt'Y /�Y <br />nspection Form Included: Di <br />Comments Included: 0 ........._... ....... <br />Business Rep's Signature Phone Number Inspector's Signature <br />INSTRUCTIONS ON BACK ` Correct:l, Incorrect: NV ( d.10XI.AIMIPILIE1 1112 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />