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t <br /> 073i30�Gg5� <br /> Waste Tire Survey & Inspection Report Inspection Report Number. <br /> State UNIM it:allforrile - Survey Form Pagel L. 2 - 1.0 7 3 4 6 7 <br /> CIWMB 181(New 04/04) <br /> Ca=rated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 7- 1011 - 0 ®Routine Q Reinspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: -XW1 `"Cou` rY*, Cy,��.�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ) <br /> //77 --r- Inspected By Inspector <br /> I l—L I r.h . I <br /> Physical Address <br /> L r6o3 S,-6.Ste. i <br /> Street <br /> Inspection Date <br /> I <br /> City State ZIP Code S � Time In Time Out <br /> Business Rep Title O AM O AM <br /> --- '� /Ti10 Se►� t "Pr'°wt lir l MOPM 11-1 0P <br /> Operational Status Tire Type Business Role Storage Type. <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill-all that apply) <br /> Tire Count(WholelPTE) 1.5 <br /> ®Active ®Passenger A Generator Q.Outdoor <br /> (� 0 Q Closed Q Altered <br /> GPS Latitude �_J,I 1 _1 I I I Q Hauler ®Indoor <br /> Lt_ ..JJ-- I O Q inactive Q Truck <br /> Longitude - I.�� �I Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply)' <br /> JJJ 111 111 J <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility FEN FSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 <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§16460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Efij <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 Compliance - No Violations <br /> 1010 Other: § <br /> Comments 1, — ire. <br /> —G'12-S—rw+p(d7nfb-rYt- t�lOrn— CP' �-P.rLf—Lc'K�-��1./I a r��� <br /> �2fi.. /��GLI�as-t-� �/u!'�it�—/� a'''te ;==—m�si�Cm�r-��°Lt7-'I►Cc_� <br /> o La fssLs <br /> Inspection Form Included:Q <br /> Comments Included:Q ny�"_ <br /> Busines Rep's (9nure Phone Number nspectoes Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 17-27362081 <br /> L .X 'A rth P L i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />