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lJ! :i A �l1 Ul)4 J ✓ <br /> oe_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> iii State of CalHomia <br /> CIWMB 181(New 04104, Survey Form - Page 1 18 .- 10 7 3 5 8 $. <br /> Cagfomla Integrated Waste Management Beard <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- g $ $ Inspection Type (Fill one) " <br /> Site Suffix: + ®Routine Q Re-inspection .Q Referral O Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: .: Smv t ,h Q CHP. Q CIWMB' Q Complaint .0 Educational Visit.Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 3 � _ � 1 <br /> Physical Address p <br /> Street <br /> Inspection Date <br /> S-}oc_ CA 9 sz13 <br /> City State ZIP Code Time In Time Out <br /> BusinRs'Rep D a r� Title O AM O AM <br /> �hh�� ' I vWn l SFru�l+Vt• m 0 PM IT] m ®PM <br /> _ Operational Status Tire'Type Business Role- Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I It <br /> r I-. Active ®Passenger •®Generator Q Outdoor <br /> l WO O CloseQ Altered <br /> GPS Latitude <br /> Q Hauler Q Indoor <br /> 0 Inactive Q <br /> Truck <br /> Longitude - Q Planned Q OTR O End-Use 4 Container <br /> Business Type (Fill all that appy)' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived'Fuel <br /> Q Used Tire Dealer Q Auto Body Q carDealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder t♦Other Li_ ,Yt` <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EN <br /> QQRC-_EMENT S1T,rg1T1Us <br /> -.... - <br /> V I A ;HAULING AND MANIFEST REQUIREMENTS <br /> -- Q Notice Of Violauon Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 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/or NOV or EXE <br /> Q O 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 MBIEEnforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 0 1 Other: §, a <br /> Comments <br /> �" _/' I ,3-ytatn <br /> --/gyp—�Ic►dr' _ - <br /> i <br /> inspection Form Included:Q V <br /> Comments Included:Q ^ ���^� 4� 6Zs� <br /> si�.pW. Slgnture Phone Number Inspector s Signature Phone Number_ <br /> INSTRUCTIONS ON BACK IIE62081 K .A M P L 1 Z 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />