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osigzoaozo� <br /> «a ; Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> LE _ - <br /> CIWMB181(New04104) Survey Form Page 1 1 10 7 9 3 6 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ K11 <br /> Inspection Type (Fill one) <br /> Site Sufflx: b L d ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local T�Lt� If Referral,choose referral type(Fill one) <br /> Identifier: y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busigess or Facility Name Ins ected B <br /> rjuL—r - /�/� b J i P Y Inspector <br /> Physical Addltess �� r i 3 5 b �-o <br /> I <br /> Street ^ Q <br /> Inspection Date <br /> f 3O� 1 <br /> CiL ty�1� <br /> State 21P Code J Time In Time Out <br /> Business Rep Title O AM 10 AM <br /> ' PM PM <br /> 17 I i perationalStatus Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I.Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude II• I—_ ! I� 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude - I I I -I- 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) f <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler - 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS J <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953.-Contracts with.Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14-CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 * 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire.Generators In Compliance - No Violations <br /> 0 10 Other. § <br /> Comments D <br /> �_ oA — �-OVl-t--U <br /> �loccL_0�1�s e cin _ — _ a � <br /> L'C C(.2s5 55, - <br /> CTL_ _ _o�atia`A,P. s �eyI <br /> n <br /> _A. LCL 0_(1 � t__r�b0_ n �V _ct- _ bs Jev_ic_j_ <br /> Inspection Form Included: 0 <br /> Comments Included: v— <br /> Business Rep' Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK C rrect. Incorrect: ( n � 62081 <br /> EXANIP 'L E' l '23 <br /> White Co :CIW Yellow Copy:Operator Pink Copy LEA <br />