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41 <br /> Waste Tire S y & Inspectionection Re ori Inspection Report Number <br /> 1n1_ ■ <br /> State of California <br /> 11 CIWMB181(New 04/04) Survey Form - Page 1 9 . 1 0 0 8 0 � <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br />` Business Profile Inspection Details <br /> TPID- � 1,1 � � � � t - � / Inspection Type (Fill one) <br /> Site Suffix: J 4t- Q Routine' Q Re-inspection @ Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CH.P @ CIWMB, 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - ! 1G► t , f ( �G(l{� <br /> r <br /> I z-7 3t— <br /> met 3 <br /> ,`- Inspection Date <br /> City State ZIP Code I Time In Time Out <br /> Business Rep Title O AM ` O AM <br /> MOPM / ' m QPM <br /> i it I <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)J (e Active (E) Passenger (a Generator 0 Outdoor 6 <br /> D Q Closed 0 Altered f¢ <br /> GPS Latitude m • 10 Hauler 0 Indoor <br /> o Q Inactive 0Truck <br /> Longitude - Q End-Use Container <br /> O Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair O Trucking Fleet 0 Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer O Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other I t <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j,A IHAULING AND MANIFEST REQUJ EMENTS -- <br /> • - --- -- — - Q Notice Of Violation Q Extension <br /> O r 0.. PRC'§' 951 `'dste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date E[1 / m / m <br /> Q O 14 CCR§-18459.1 (a)(b)(E)-Tir6"I rogram,lD Number from CIWMB <br /> O O (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms find Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities �= <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> CommentsA/�) lye xp /y / ! / <br /> 1 t� 4 �.�'-��,'f-i^ T f/'c. JA^r^to <br /> Inspection Form Included 0 <br /> Comments Includedi.__ j ..:_�. .,z_. - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:16 Incorrect: ( EIY ."11 P ILIE1 II3 62081 <br /> ■. White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />