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0804904001s <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ •'tear- ■ <br /> Calllornla I 1 1088351 <br /> CIWMB 181 tNew06104) Survey Form - Page 1 <br /> Calilornla Integrated Wast*11—g—M Board <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• ' '` - O 1 Inspection Type (Fill one) <br /> Site <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ^�� /� If Referral,choose referral type(Fill one) <br /> Identifier: L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> I Inspected By Inspector �p <br /> Physical Address <br /> a4 $p <br /> Street �/� 1 <br /> ( �t/Q C� C t q53�`� I Inspection Date =01 <br /> Cdy CJ - rate ZIP Cods Time In _ Time Out _ <br /> Business Rep Title I O 0 O ®AM �i O ®AM <br /> -r- �- -m�PM I ' ��'� QPM <br /> wrff - -- -- - - <br /> . - -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) - <br /> (�� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l ; <br /> ' r 1 ®Active #Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> - = D Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill ail 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 ®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 MENFORCEMENTT S1TATU8 <br /> OMI!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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 1:11 / 111 <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required(or NOV or FXTJ <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 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 /> Q Q Other:,�§,,,, <br /> Comments ch,0­11 t��Iw�S date - <br /> (.( A � G�CS� Q <br /> vow CT T �na �s fJiL•r <br /> Inspection Form Included:QI (� <br /> Comments Included:Q— °2O- 9-" <br /> Bu ess Reps igna ure Phone Number Inspector gnature Phone Number <br /> INSTRUCTIONS ON BACK M P L E 12 3 62081 <br /> ■ While Copy.CIWMB Yellow Copy Operator Pink Copy LEA ■ <br />