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=L rt Inspection Report Number <br /> Waste Tire Survey & Inspection RepoI _ ■ <br /> - <br /> * �;p <br /> State rWMB181(Nrnla Survey Form - Page 1 11 - 1 0 7 3 4 9 9 <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- v J Inspection Type (Fill one) <br /> I Site Suffix: ! 2 7 S / ( I0 Routine 0 Re-Inspection 0 Referral 0 Observation <br /> Local - — / I If Referral,choose referral type(Fill one) <br /> Identifier: �j cL4, t v.� C��un��-vi_J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0 � <br /> `iSIO A1 ; �ctzck <br /> Q Inspection DateIF <br /> Si j'e 7!P CmOf Time In _ _ Time a Out <br /> Business Rep Title I O AM I O AM <br /> rT�T�/v�-� �rhY�1�?�(rv��'1/u �;�.Svp�I S�T( i 1-- � • I -- -- �® P M ® PM <br /> 1 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) /(n <br /> t ® Active Q Passenger (6 Generator O Outdoor <br /> O O Closed O Altered <br /> GPS Latitude 0 Hauler Q indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) IL t <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body 0 Car Dealer Q Collection O Crumb Rubber �- <br /> Q Service Station O Hauler O Agriculture O Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O -- - <br /> 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 O Referred/CIWMB Enforcement <br /> O 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 /> O O Other: § <br /> Comments L �7 <br /> —'`6'�E,t~1�-�-k ��=- C�=�=�i�Z.m-,-5+'�`-�,_Y� •i_✓t_mt_oK'i- �xx.__�t(}i�cJ�,,��►+n.� <br /> _ r u �i•��v 1 I�I- -}-t K t 'tfn`�tsf- N� v�>v�Com+f2itiL._V_(./�' —TP I �_?'r . <br /> Inspection Form Included: Q 5/ <br /> Comments Included: O �/�wA/ ,t J fib$ �O 6 2 3 <br /> Business Re Signature Phone Number Inspector's Signature Phone Number <br /> - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( X A M P L E f 2 3 62081 <br /> . White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />