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= Re ort Number <br /> Waste Tire Survey & Inspection Report *pectionp <br /> ■ e � State B California Form - Page 1F1 8 - 1 01 3 5 8 5. <br /> CIWMB 181(New 04104) Survey g -_..- -. <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> W.�n r,wura' y.'yM;�' :InspectionDetails a; <br /> ' <br /> TPID- `Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 71 ,j 0 CHP 0 CIWMB 0 Complaint Educational Visit 0 Other <br /> 7: _ <br /> Business or Facility Name Inspected By Inspector <br /> (Physical Address ( `' Lj±t(f <br /> 7 <br /> f _ <br /> Street 1, Inspection Date j (. 1 L' �✓ i� <br /> I– Time In Time Out <br /> City State ZIP Code �. <br /> O <br /> AM <br /> Business Rep Title T i <br /> ! / f -1�� AM PM OPM <br /> Operational Status Tire Type j Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply)' <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O (* Closed 0 Altered <br /> GPS Latitude F=7_10 <br /> 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude – ,��_ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill ail that apply) <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 Q Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B -.Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> V A, HAULING AND MANIFESTREQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 / <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 0 in Compliance - No Violations <br /> 0 0 Other: § – <br /> Comments r �' r { <br /> ,nlC,' ,(l 0 °(J <br /> Comments i<< r ', ;1 1, •. f..t t� <br /> i tt j— <br /> r )ri r <br /> Alf {�_ ''?"t V E' "i.' t U 'f ��. /' U 7 :moi.✓"�F'jt £Y1 11_ [ j ?ct r( t9 in C1 (ft (tr11 L;k1�j 1 <br /> ( C� P' t'•tCdCC !{ :F: '�� 1fl ( ti✓E� a/�;G{�CiYv, Itis ( I, ic( �ivi„1 UL)G} 1{ '_ {i �:rU�.`t:.'� C7r,ri <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ - - <br /> Business Rep's Signature Phone Number Inspectors Signature , ._ Phone Number <br /> .._,. 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X i; A L 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ■ <br />