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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r�r State of California <br /> �r CIWMB 181(New 04104) Survey Form - Page -1 C 5 - 1 0 137 " " <br /> r:alifomia Integrated Waste Management Board <br /> Part A-Survey BLUE �I}N PEN <br /> Business Profile Inspection Details M1-ir-04 <br /> TPID- ? r f� Mot <br /> Inspection Type (Fill one) <br /> Site Suffix: [ 1 3 WF91 q 1 ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: 0 moi/I 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Vu Inspected By Inspector <br /> RCLM10 1 Temp-- <br /> Physical Address V <br /> S (Y-+ - <br /> Street 20 <br /> inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM m O AM <br /> i m - m0 PM 0 P <br /> ��vs? Jtilo �a _ R'e�col� f <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r ' j I O O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 . ®Active assenger ®Generator 40 Outdoor <br /> O 0 Closed &,Altered <br /> GPS Latitude { ® Hauler ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude — I Q Planned 0 OTR v End-Use ®Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantier 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection o Crumb Rubber R ` ^r1^„t �,D,(,,,.�. <br /> Q Service Station Q Hauler Q Agriculture Shredder O reth reth �V�( yul�ltl��yf 'KQt�• I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V I A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 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 Date M / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Lags within 90 days (Required forNOV or EXT) <br /> Q o 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> Q o 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments jR .,F,-v `' Dr.�-, ` <br /> Ips �4w)__ �.na _._..��5 <br /> �,ves WhQI? -f fires_. Tf'fi"C , _ v+ +'►'l Q;t Alc <br /> + , -TKS hLt+`4 also reCCLVa Crus b r ,I 6e orn <br /> Arre�c ccs <br /> Cb <br /> 1 s or 61f W1 <br /> Inspection Form Included: Q <br /> Comments Included:® *nt — — —B stn s e 's Si ure Phone Number s nature Phone Number <br /> �--�/ szaal <br /> INSTRUCTIONS ON BACK Corr t: Incorrect: (� I� X R M P L 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />