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PF <br /> 40 Waste Tire. Su�y & Inspection Report Inspection Report Number` ■ <br /> State of California <br /> �CIWMB181(New04104) Survey Form - Page 1 $ - 0 3 0- 9.8 <br /> Cal ifornia'lntegrated Waste Management Board <br /> I" Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n Inspection Type (Fill one) <br /> Site Suffix @ Routine Q Re-inspection Q Referral <br /> Observation . <br /> Local — i' If Referral,choose referral type(Fill one) <br /> Identifier: Sat/\ Q CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br /> Business or Facility Name _ i Inspected By Inspector <br /> ( k`2lel / f('�L c tt (/l( � I 1 _ ` <br /> i Physical Address J ` r< J V{ i t <br /> --- <br /> " I: <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title f I- n �, EE.0 <br /> AM O AM <br /> 0P � � m OPM <br /> , <br /> (�vW <br /> I , �I J I ~Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a' Active Q Passenger Generator Outdoor <br /> Q Closed Q'Altered <br /> GPS ®Latitude m . Q Hauler Q Indoor <br /> O <br /> Q Inactive Truck } <br /> Longitude - Q Planned 0 OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair &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 Q 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 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 v14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Qi Q 14 CCR§184)59.1 (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 /> 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 1'45d R§18461 -Manifest System Requirements for Waste Tire End-Use.Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements fbr Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> i . Q Q Other § <br /> Comments p t r '' �` / ' <br /> Comments <br /> h �,a�. I �t��iIty/\ � f.. j0.1 e, f.��f 1U��:'I/-�tt,'! K) 5 A [, t(,' 7h, 5 Ll�' �t�' (-frf j <br /> �tJ+� �o-( }�� �ee '_ tt( V C< cct�r t�)c��f� �ii� �vcu ./ala �e '�cC,d t�l�lc`� 14 <br /> ✓ L :l ✓►orad t -O yl -.� <br /> a f � t I . GTL.. . r r�J u r .u -, t � i (�! c:r �, Wit_ u� . <br /> Inspection Form Included <br /> ` <br /> - 1 <br /> Comments Included: Q ... -. - .... . - --- - - -.... - �^ - <br /> -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ., , M P O E I' 62081 <br /> ■ White Copy:CIWMB •Yellow Copy:Operator Pink Copy:LEA- ■ <br /> i <br />