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082G�04�01 � <br /> ¢er= <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState of ■ <br /> C[WMB181(Neia Survey Form Page 1 I1 1088175 <br /> CrvYMB 181(New 04104) Y <br /> caiifemia Integrated Waste Management Board <br /> Part A-Surve ' _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / TS 0 ' Inspection Type (Fill one) <br /> Site Suffix: I Routine Q Re-Inspection Q Referral Q Observation <br /> Local <br /> 1 � If Referral,choose referral type(Fill one) <br /> Identifier: � �pq '�/ CpL U Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �lJf o <br /> Inspected By ,ems Inspector <br /> C_ <br /> Physical Address DYE l o_ N � _ V ��wt l •�"���>rJ�]—� <br /> l i8/3 NIWAW lelvd i <br /> Street 53 © ► / I V D <br /> Inspection Date <br /> Ly Sta!o ZIP Coda Time In Time Out <br /> Business Rep TitleO AM f O AM <br /> O PM O PM <br /> Di4tn'd- /94 j,� _- __•/�AL._{NarIG___�O/�.' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> •Active -Q Passenger •Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill ell that apply) <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 O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other ��� <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility KENFORC-EMENT STATUS <br /> V A 'HAULING AND MgNIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q I 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 <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 for NOV or EXT) <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 Q Referred!CIWMB Enforcement <br /> Q 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 C-ompliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments 01 <br /> e►7 %tuts--��. - ora�hc oa_.✓� .P <br /> /���1_en%J���tat;,;Q,_�u7-e-G l•� _ as 1I�...: r�, - --�4�-e_-�r...4.p.�. ! <br /> or <br /> I <br /> Inspection Form Included: Z <br /> 1 r 8 <br /> Comments Included:Q Busi ess Rep' nature Phone Number Inspector's Jt:Phone Number <br /> INSTRUCTIONS ON BACKrrec Incorrect: X a M P L E fl 2 3 62081 <br /> ■ White y.CIW B Yellow Copy.Operator Pink Copy.LEA ® ■ <br />