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08i6404G06a <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> s <br /> CIWMB 181(Now OMOd) Survey Form - Page 1 1 5 - 1072835 <br /> am.r„ W. gra.dMO.M...9—.te <br /> Part A Survey ..re BLUE OR BLACK INK PEN <br /> - _ _ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) — -- � <br /> Site Suffl 13 1 1S ®Routine 0 Re-inspection 0 Referral Q Observation <br /> Local —I If Referral,choose referral type(Fill one) <br /> Identifier: �JO_ � " JLf_ O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name 07 <br /> Inspected By Inspector <br /> I sax To� , 4L I�c- Co I _ <br /> Physical Address ' O I L <br /> Street 1 0 1 D g <br /> � Inspection Date—— CA 9S-'3'o1) <br /> ����_ I Tlme In Time Out <br /> State ZIP Code <br /> Business Rep <br /> � Title 1'AGJtPS Pf p(1h m 0 PM m m O PM <br /> _ — - --.- 'n ta 7,, 0peratio I Status The Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r ° ®Active ®Passenger le Generator ®Outdoor <br /> O Closed O Altered <br /> GPS Latitude -� -� Hauler O Indoor <br /> _ O 0 Inactive Q Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) - <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O.Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A ,HAULING AND MANIFEST REQUIREMENTS <br /> O Notice of Violation O Extension <br /> O O i PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M 1 m 1 m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459 2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O -- _....._. <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§la462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O 1 O 1 Other//:1§ <br /> Comments 1)f„[p-r,-�-t`vt n f/1 CJ,Jap�-"{'1Qy1 --}7�;s II notes d ik Fa t►vwi ' 7 )6�m� <br /> ra�l,t I `�ryvY 1 r�c W6 5,ft � t re-s h acs(epi b �/ U BVI Lt`�✓+�o✓e 0It 5/19,0• <br /> T� 4- C� ut awr-es�e noos�lj.._from a �oeop1e.-1nLks& <br /> oIF ca�-fs___ m ecce v� ' S '11e es u _ s1,cr- <br /> a <br /> Inspection Form Included:O ' p Q /¢7 <br /> Comments Included:O — 95`f�`� S IgIt v9C?(060 <br /> uslness e s Signature Phone Number Inspect s Signature Phone Number <br /> � ,�( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:x�, �J t: X A M P L i 1 '2 3 ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA - <br />