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07i9014013a <br /> ■ ggg- Waste.Tire Survey& Inspection Report Inspection Report NumberState ■ <br /> gg CrW.M f 181(Now <br /> Survey Form - Pagel' 1. 4 - 10 7 3 4 6 9 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board . <br /> PartA--Survey BLUE OR BLACK.INK PEN. <br /> Business Profile Inspection Details . <br /> TPID- -1 6 d ( Inspection Type (Fill one) <br /> Site Suffix: T Routine Re-inspection Referral <br /> • p Q.Observation. <br /> FTle <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: . q�.c�yt �9ou�af Q CHP Q CIWMB io Complaint Q.Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical Address <br /> I t <br /> Street r <br /> Lock: <br /> Inspection Date <br /> City StagPbC d Time In 1 Time Out <br /> Business Rep Title M • m 00 AM 0 AM <br /> PM m• m PM <br /> I_l'JafS v ss rv� I w W'A'X Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(Whole/PTE) I l l T� (Fillone.only) (Fill all that apply) (Fill'all that apply) (Fill.all that apply) <br /> Q Active ®Passenger. 0 Generator ®Outdoor <br /> 0 0 Closed O Altered <br /> GPS Latitude Q Hauler - O Indoor <br /> o ® Inactive Q Truck <br /> Longitude - Q Planned Q OTR ®End-Use Q Container <br /> Business.Type (Fill all that apply) ~ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader0 Dismantler Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> I <br /> Part B-Inspection of Waste Tire Dealer;Generator, Hauler and End-Use Facility JENFORCEMENT STATu_S _ <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Q <br /> O O PRC§'42951 -Waste Tire Hauler Registration and Transport of Tires Violation Extension <br /> O O PRC§42953-Contracts with Registered•Waste Tire Haulers. Compliance Deadli e <br /> O O PRC§42956-Registration/Decal in Vehicle. <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 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 /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred!CIWMB Enforcement <br /> Q 0 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 1 0 Other: §, <br /> Comments y <br /> '^�Q.•— I �a C o.�-rtTn �'r+r� J�,.C GIQ(� e� �G I ��SiVlt*y1_—( `(C+, - -- — <br /> ' f� T..�r C3'Y�—rr� �L��•tQ.�c�._.e_V1AfltiL✓ � �iLLAt.,l�'�f �(�f_N-C7�t-- V <br /> s, [7J t CZr <br /> �L�G C I'�YAH1t•��n � ��]1 e5 �D V i D�c��•,` ♦S <br /> Inspection Form :nc <br /> ncluded: Q <br /> Comments luded: Q x �'� !o tb <br /> Busin s p's.Signature Phone Number Inspector's.Signature Phone Number <br /> --— --- - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X fl Ilh P1112131 <br /> ■ White Copy:CIWMB. Yellow Copy:Operator Pink Copy.LEA ® ■ <br />