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C ;_ Waste .Tire Su(Sey & Inspection Repor Inspection Report Number <br /> o¢� ClWMState 181(Nrnla Survey Form - Page 1 Il - 10883 6 2 <br /> CIWMB 181(New 04/04) Y g <br /> California Integrated Waste Management Board `� <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI - <br /> Site Suffix _ O I Inspection Type (Fill one) <br /> Site : Q( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ^�" /� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �•l•�l� lam/ (7 Inspected By - Inspector <br /> Physical Address o LL� <br /> I 3 0/ 1�oa - - -- <br /> Street <br /> Inspection Date <br /> City State Zip Code Time In Time Out <br /> Business Rep Title 0 AM --- l , ( /� AM <br /> O �_ - 1--I 5 ® PM �! _� ' LV ® PM <br /> *—= — —J Operational Status Tire Type Business Role Storage Type <br /> (Fill <br /> that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) (Fill one only) <br /> f ' Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - , , Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 Q Crumb Rubber <br /> IQ Service Station Q Hauler Q Agriculture Q Shredder Q Other I t <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS x- <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> Q Nolice Of Violation <br /> Q Q Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/ -1 MB 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 ® In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> �S_ cmc:-l_'� _ 0�c _ 'ed�s -.sl�ar_Qc_�b_�-f"h�-�' -f�'uck-� ��o►�►�.. a,� � <br /> _[+GZ 6(�_t�sQ gr'OS . � O�t ca ,�r �S �t1a.S C_I D_ —•�_—�►'YLf GLS�/'S <br /> a�c4 3 �o_ Van sem ' wi h V 5�1 o .ow_ee-e- b aGk eve a <br /> Inspection Form Included: <br /> Comments Included: / O1rV�Q� - — — r ---9'� <br /> (!.L <br /> Business Rep's nature Phone Number Inspector' ignature Phone Number <br /> INSTRUCTIONS ON BACK Co rest: Incorrect: 62081 <br /> EXA �IAPLE1 !23 <br /> White Copy. IW Yellow Copy.Operator Pink Copy:LEA <br />