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Waste Tire S ve & Inspection Repo�t <br /> Inspection Report Number <br /> � <br /> Stateof California <br /> CIWMB181(New 04104) Survey Form - Page 1 Il - 1140783 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- //++�� �-7 Inspection Type (Fill one) <br /> Site Suffix: f V 3 [ O I • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S CV) J 'a ��f� �}u,n�'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name A ` Inspected By Inspector <br /> It) `tkn��.� <br /> Physical Address <br /> 3rl 5o i�. t.,� ;l ion Wei <br /> 11 <br /> Inspection Date i �, � Q <br /> 5j'o3*n� (� 11!:5X-5 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �. 0 PM O PM <br /> Jes o46s n�U^ ��')e 0Operational Status Tire Type Business Role Storage Type . <br /> �( <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ,eJ <br /> f ' Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered NA N�`I <br /> GPS Latitude ]A I Q Hauler Q Indoor <br /> O Q Inactive Q Truc�l <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q 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 • Hauler Q Agriculture Q Shredder Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -VIA HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FU m I 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 I 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 <br /> in Compliance - No Violations <br /> Q Q Other: § 1 tt <br /> Comments 10tl ` \ CL�jo v���Ct. �3s� n T rN -L -f 00 ►r 11 S �� L �— <br /> ow_A-s1 car 5 Yl c c�1'- <br /> N)_0 �1i Inspection Form Form Included: Q <br /> Mai <br /> Comments Included: d <br /> Business Rep's ignature _ Phone Number_ Insp <br /> ------------- � ��o(ssSignature -Phone Numbe— <br /> r <br /> INSTRUCTIONS ON BACK Correct:* incorrect: Xc )� �V E�P�� ( 111]2 �3] 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />