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o8�asosoo6s <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ��.[.[as State of CalMornla <br /> CIWMB 181(N..04104) Survey Form - Page 1 I 2 10 7 2 8 <br /> Calffomis Inmgratad Waate Nanagemenl Board <br /> PartA-S=e BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- % ^ �] Lo <br /> / Inspection Type (Fill one) <br /> Site Sutfix: p( ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: T r _! _ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I �c aP CC) I (� <br /> PhysicafAddretf <br /> 3-0-203---S. 144 �1►- �iJ �- e�� ��G <br /> Street <br /> Inspection Date <br /> City J State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> L .. r r- - L-=t/y!_/.P�l�.:c- �Vr. - I ODIr F7,PM `JJ 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t f I&Active ®Passenger ®Generator ®Outdoor <br /> Latitude I Q Closed Q Altered <br /> GPS LJ-_•L-1._L—� ®Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - I I Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) - 1 111 <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 ®Hauler Q Agriculture Q Shredder - ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility BENFORCEMENT STAT S <br /> V A HAULING ANO 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 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / LE <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 ort] <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 Referred/C-IWMB Enforcement <br /> 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 1 Q 1 Other: § <br /> Comments LDII <br /> aLin_ _`YJ <br /> hSGQP�, -Cr o . � .v�vl �f Yl tb�—_ <br /> 4AJ <br /> Inspection Form Included:Q <br /> Comments Included:® /1/ (�-� - <br /> 13Hess Rep's Signature Phone Number Inspector's Ignature Phone Number <br /> INSTRUCTIONS BACK IE X A M P L E' 1112131 62081 <br /> . While Copy CIWM8 Yellow Copy.Operator Pink Copy.LEA ® . <br />