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i <br /> Waste Tire Su&y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board Survey Form — Page <br /> _ <br /> e 1 y 1127649 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> , <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix:�� (,/ 10 L9o(—e I ? ; �) <br /> _ Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 )" �^M If Referral,choose referral type(Fill one) <br /> Identifier: . 'Ln r� Q CHP Q CIWMB Q Complaint_ p Q Educational Visit Q Other <br /> I Business or Facility Name U - _ <br /> Inspected By Inspector <br /> Physical Address J Lt <br /> O Ll <br /> lf <br /> _ __.. ._.__....... ._m._... ..._. ._.__........ <br /> ..._....._. _ . <br /> srt"eFr , <br /> (� / Inspection Date / ) j / Q <br /> � _zTP "" Time In Time Out <br /> 5f ale Gly <br /> Business Rep _.... L__.. .... i" <br /> Title J i O AM �/ O AM <br /> € <br /> QPM <br /> w 0 PM <br /> Operational Status 1 Tire Type Business Role <br /> Storage Type <br /> Tire Count(Whoie/PTE) r ,r' (Fill one only) (Fill all that apply) (Fill all that apply) I(Fill all that apply)'. <br /> 1 <br /> Active Q Passenger Q Generator O outdoor <br /> I._""."".Y"_ p <br /> GPS Latitude i Q Closed Q Altere <br /> Q Hauler Q indoor <br /> Q Inactive % Truck <br /> Longitude Q Planned O t}TR O End-Use f,ontainer <br /> y ,fit € , <br /> IxS Type �IS � �� .,,' 2 iE ,"s <br /> ME `241 <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 Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O —o— <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FJJ / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> Q O 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: § p <br /> Comments ? <br /> ?J�'d Q f Et1a 5le -f7fe S Si h ce [?ke il'(19A s W. 4,..0 t 1 611 .il� <br /> Q tri Service tti ,?oU c� alt w.aru��st <br /> K r -> 7, /. A <br /> Inspection Fora lnciuded: O <br /> Comments l,tCluGvG'„ 0 <br /> Business Rep's Signature Phone Number sign?#ure 'Phone Number <br /> `� 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X I- ti A,� � j <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />