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i <br /> ■ a Waste Tire Sur icy & Inspection Report spection Report Number <br /> 8➢C� -State of California <br /> CCCu .CIWMB181(New 04/04) Survey Form - Page 1 - 12 - 10 1 '0 8 8 -4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- / h - 1 inspection Type (Fill one) <br /> Site Suffix: lL U EII Routine Q Re- . Q Referral Observation <br /> Local �\ . 1 If Referral,choose referral type(Fill one) <br /> Identifier: ` �(�Ga �L vu.f. �_ f,( h_t „' Q CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br /> Business or Facility Name id - ---- --- <br /> 11 _ inspected By Inspector <br /> Physical Address �3 r c) �f�.�- (� 1C <br /> Street Inspection DateCA <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> EE : <br /> m O PM DI : <br /> m 0 PM <br /> 1(Y <br /> I. <br /> Operational Status Tire Type Business'Role Storage Type <br /> Tire Count <br /> (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger (a Generator to Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m . Q Hauler Q: Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned j@ OTR Q End Use 0 Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q 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 Hauler Q Agriculture Q Shredder Other l � CQ Service Station k t (2 c <br /> r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A 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 /> Q .Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <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 EX7) <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 /> t <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 /> Q Q Other: § <br /> Comments <br /> lr( C/lC (! <br /> s . JiPl"J-e(f <br /> LickVe 7P1U nyl rf of d.lrr -rt � � "Fc(P � pig4d (,_p_ `JI in 1-60 <br />} / 1 <br /> nil ' ' n� 00 JD L(�t�✓a /` , es/s <br /> Inspection Form Included: <br /> Comments Included: Q - - -- <br /> Business Rep's Signature Phone Number Inspectors Signature + Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: ( vp 3 .A ,� , p r, x 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> r <br />