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0. 42040456 <br /> rrr. <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState of ■ <br /> CUCrWMB181CaliforniaNSurvey Form Page 1 1 3 1 0 1 3 5 3 4 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details* <br /> TPID- f _ O Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: h _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> -) 4�r <br /> Physical Address (^J <br /> I Street T 4 S - <br /> `�-"Cl�.t_ I <br /> r Inspection Date <br /> c7r SAO Time In Time Out <br /> City �- � State ZIP CGo�e <br /> Business Rep I I-•�y Title EE ' m® PM m ' m ® PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> j <br /> Tire Count(Whole/PTE) I j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> , S l � <br /> ®Active Q Passenger ® Generator Q Outdoor <br /> Latitude � �O Q Closed Q Altered <br /> GPS L_ J ® Hauler ® Indoor <br /> �_E <br /> _-_ _ O Q Inactive ®Truck <br /> Longitude - i I I I JI Q Planned Q OTR ® End-Use Q Container <br /> Business Type (Fill all that apply) J JJJ <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 ® Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture ® Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility KENFOREEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 FXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q ® 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 C-IWMB 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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �, ._a.nspcer;,�. � k�,�sscat..._.—fZcL—r.��s_,�..+'.�c�.�-r.►u. <br /> Irz,� evP�—(hAma�ne�Q�_axtd_$ u�^d--ern #,�e_v,nQ.lZdLaat_I? etm r► >ts_ —�/lnre�11— �5.$� <br /> CTL_sU ke <br /> �� - - �P'`�— —•- - - �� -fes���� �Isr_c.nc �-s-c�ksa_IZor���;k <br /> Inspection Form Included: Q a <br /> Comments Included:0 - _!lle . <br /> Busine_/ep7sgn ur ne Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BA K C r�r�eat: IncorrecjEjXjAjMjP[LjEj 111.2 3 <br /> ■ White Cop CIW Yellow Copy.Operator Pink Copy LEA ® ■ <br />