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Waste Tire S ,, ey & Inspection RepoH.Jnspection Report Number <br /> SS".a.. State of California ■ _ <br /> igam <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 8 .10 13 7 7 5 • <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q V - Inspection Type (Fill one) <br /> Site Suffix: Q Routine I Reinspection Q Referral Q Observation <br /> Local s If Referral,choose referral type(Fill one <br /> Identifier: i U0n �� t <br /> (if Q CHP Q CIWMB Q Complaint Educational Visit Q Other <br /> Business or Facility Name U — — <br /> �^ Inspected By Inspector } <br /> Physical AddressVJ <br /> h <br /> Street <br /> (� Inspection Date <br /> .� UCSL /y 117 ()'A <br /> Clty State Zip Code Time In Time Out <br /> Business RepJJ,/ Title <br /> ��Q 2 I� AM Q AM <br /> V <br /> y I 0 P Q j ' � QPM <br /> uNaC V If <br /> - — - <br /> Operational Status Tire Type Business Role Storage Type <br /> r (Fill one only) (Fill all that aPPIY) (Fill all that apply) (Fill all that aPPIY) <br /> Tire Count(Whole/PTE) <br /> C,) Active Q Passenger Generator IF) Outdoor <br /> O <br /> Latitude O,Q Closed Altered <br /> GPS m • (4) Hauler 0 Indoor <br /> p Q Inactive (5 Truck <br /> Longitude - Q Planned Q OTR @ End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 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 /> T__ ___� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ----- ......I—............ --- -- <br /> V A HAULING AND MANIFEST REQUIREMENTS_ <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation (3 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 <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 EXT) <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/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 Q In Compliance - No Violations <br /> 010 1 Other: § <br /> Comments / ` <br /> j`.f ft1 �s/�'C �1tsr1 �'ic j f� tt �(u f /Io)''.itnr, {.06 d'lUfF tf � { t i �'y( 1-(/ 1tU <br /> tiC{f(JF� ; CrrPr �! Gf� �rs� � t:i1� r�i /— /p1 3'7 . U. PevL- <br /> 141rde 10 1AAW(w IsJorooe .�ic,� ,� r( LWI W5 akin l Iti1v if c,F U. rrsf: <br /> fi(eC On 5ifP 1-6Ve Vii'I, trPjt4Cr& f-' Cs- hit„1 C'C.? walrf �trN5 GAG <br /> Inspection Form Included Q 2 J I ' <br /> Comments Included: (DlilI l <br /> Business Rep's Signature - Phone Number <br /> L_.. I..n. telLcltoflry's <br /> Siagn.�atu.�re .r Phone_�Numl;berr <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: ) , •, „fit p L E l 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />