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'LB9. <br /> Waste Tire Survey & Inspection Report . Inspection Report Number <br /> Lo <br /> CMfMB181(New 04/04)State California Survey Form Page 1 1 2 10 7 3 4 8 3 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / ILI 15- 1 'V 2 Q ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��td/1 � ti ��' � Q CHP Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name UN. Y Inspected By Inspector <br /> (Physical AddressI 3 ' !' �C�tthnLLl!�G1S+—gam fir�-,J <br /> i / '-I 1 •S tnl. �'hc1.HrS o� I <br /> Street <br /> Inspection Date <br /> S.I-V 4--ty n CA °t-S'zo b I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> 11] m 0 PM m m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I I <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE). <br /> J Active ®Passenger I®Generator . IN Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude � . Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude � 1-1Ll F1Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair ®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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility KENFQRGEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> xtension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q E <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 <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 FXTJ <br /> Q I Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q I Q 14 CCR§18460.2'-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 In Compliance - No Violations <br /> Q Q Other; § <br /> Comments l� <br /> --£�>r-1/-vrv�t.¢./--fc�Ju�—/��c/����i♦'!�',_t`.-Cf1_Q.rri.�l.��4.�,rn.�.f 3_S� �-iTic�Li_s�o�. <br /> Inspection Form Included: Q <br /> Comments Included: Q ss Rep's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS O BACK Correct: Incorrect: 62081 <br /> EXAMPLE+ fl '23 <br /> . While Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I -- <br />