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a ' <br /> Waste Tire Su & Inspec#ion Report p <br /> �.n <br /> ection Re ort Number. <br /> State of California ~ <br /> CIWMB181(New 04104) Survey'Form - Page 1 17 - 10 7 971-5 <br /> California Integrated Waste Management Board <br /> Part'A- Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID: Inspection Type (Fill one) <br /> Site Suffix: L( T- ,7 J; Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �` Un/r 1. i, - Q CHP. Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r i <br /> Inspected By Inspector <br /> i Physical Address <br /> Street -� <br /> Inspection Date l� <br /> City State ZIP Code Time In Time Out <br /> >E Business Rep Title 0 AM O AM <br /> I / I� EE 0 PM a] 0 PM <br /> ( __ _ Operational Status Tire Type . Business Role Storage Type <br /> tl T <br /> Tire Count (Whole/1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> TE) f <br /> Q Active Q Passenger 6) Generator Q Outdoor <br />` O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 /> 0/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 1 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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I' Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> ff Q Q 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 -Tire Program ID Number from CIWMB <br />.i Q Q 14 CCR§18459121 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> I� Q Q 14 CCR.§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> is <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 /> Q Q Other: - <br /> I!i Comments=-�. 1GY�! (/>>� .(.� i (� ,l 7� ;�',• i Y �•' 117! tl! +�r v' <br /> r -- j 1 r <br /> 1: lr�lofil ✓Ci !1 <br /> a <br /> Oil L. <br />+�1 Inspection Form Included: Q f <br /> Business Re 's'Si nature ` Phone Number Ins ector's Si nar , F f f <br /> Comments Included: Q. . <br /> p g — p. g ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ' `w. .Grille ,fir 1 3 62081 <br />'! ■ <br /> Pink Copy:LEA <br /> White Copy:CIWMB Yellow Copy:Operator ® ■ <br /> I <br /> e <br />