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•iit. <br /> Waste Tire Survey & Inspection Report _ Inspection R@dORNI f17A6T� <br /> ,� Snro al California <br /> C"MB 181 IN-04104) Survey Form - Page 1 �_.I 4 - 1 01 4 71 1 <br /> "11—Li Intag—d Waste Management aoard <br /> Part A-Survey __ BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- ^� - Inspection Type (Elle one) <br /> Srie Suffix: ` ! Illi / i®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ayk i1 11{ (/1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityC/J! <br /> r Inspected By Inspector <br /> °l - ! D 1 L�, r� -�Zt-� <br /> Physical Address <br /> Street <br /> /Uaj&�a O q 5-3` I Inspection Date 1 <br /> rty — !V/ fated Time In Time Out <br /> Business Rep [� Title <br /> (j s � O AM O AM <br /> Ox�V\I1GV 1 tQ L m mOPM m' OPM <br /> —OrI <br /> j C'Y. Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 I I 1 C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> I I O Q Closed Q Altered <br /> GPS Latitude �f i�,� Q Hauler Q Indoor <br /> i-J O Q Inactive ®Truck <br /> Longitude I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 <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 Service Station p Hauler Q Agriculture Q Shredder ®Other [OXV ` <br /> r /�t�I�DY-k�I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> - <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 i (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 1 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 ®in Compliance - No Violations <br /> 01 Q Other: § <br /> CommentsY�cQe• �}�1 n �n _ 1'J Q ���`� i� <br /> trx= U r rriT �et1-VLC ---t I _ frau Rz7f' <br /> -}r_&Z ��_ fay 1Qca f Yzxi)ul . JM-e, U���`� C )ast Rcyme {�t <br /> Nefs__n srl e a��1o�k do-ne 2�� _;r,0_ <br /> Inspection Form Included: Qp C1JJ l � <br /> Comments Included:® d�S 414-SI -;_m� <br /> i Business Rep's Signature Phone Number Phone Number <br /> INSTRUCTIONS ON BACK Correct: correct:X(�P X R Nt P l E: 1 2 3 62081 <br /> . While Copy:CIW Ma Yellow Copy Operelor Pink Copy:LEA ® ■ <br />