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�r A �JZ. <br /> " Waste Tire Sine & Inspection Repo Inspection Report Number. <br /> ka <br /> Y p p State of California CIWMB 181(New 04/04) <br /> California Integrated WasterManagement Board Survey Form - Page 1 1 \Li/j� <br /> 10 1. V <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j,/ JJ,� / I Inspection Type (Fill one) <br /> Site Suffix: 0 j `( t/ I Q Routine, (e) Re-inspection Q Referral Q Observation <br /> Local — r If Referral,choose referral type(Fill one) <br /> Identifier: i ��i ( f(j�(,(�p') � U' �# Q CHP Q CIWMB Q Complaint Q Educational VisFt.Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> i ¢ l r4� i r <br /> Physical Address <br /> Street Cit � I� f' r. C Inspection Date <br /> tr lJ J <br /> `-, / / .fi.� '� ..��t!}�, m <br /> City State ZIP Code Time In Time Out <br /> Business Rep 1 Title O AM O AM <br /> ELI • m PM m •.m PM <br /> / Operational Status Tire Type Business Role Storage Type <br /> f LJ_LJ' �_ (Fill one only) (Fill all that apply) (Fill all.thaTapply) (Fill all that aAPIY) <br /> Tire CounY(Whole/PTE) , <br /> Active. Passenger (61Generator Outdoor <br /> Closed Altered <br /> MO <br /> GPS Latitude m • (f Hauler 0, Indoor > <br /> O Inactive Truck <br /> Longitude – 0 Planned ( OTR <br /> End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government (jD Retreader. Q Dismantler Q Tire Derived Fuel <br /> @ Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station (8 Hauler Q Agriculture . Q Shredder. Q Other I I <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 Notice Of Violation Q Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB V <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use.Facilities <br /> O. O 1'4CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q O Other: §. <br /> Comments `Q_+t}C.s i U1�2.. <br /> rLd.f 1r1 2Xi <br /> (4A { ��()V <"iir� l . ftrtf fr' f4&' A(! ' /161"o L4 I j} 'vrJ'i �tft' `Yt �(rj Ct tJ <br /> CIS P��iarC? 6iCf"1;_ 'r �`,� /; t1 � r,t�f rEltt Jt <br /> Inspection <br /> Comments Included: <br /> Business Re s Signature PhoneNumberInsp ctors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X�j WK E x I.AAA I P IL� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />