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0925-9040S70 <br /> Waste Tire Su.vey & Inspection Reporp Inspection Report Number <br /> State of California <br /> �CQd. ■ <br /> California Integrated Waste Management Board Survey Form - Page 1 Il. 112759-J3 <br /> CIWMB 181(New 04104) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- —T Inspection Type (Fill one) <br /> Site Suffix: M O 1 % 160O � 40 Routine 0 Re-inspection 0 ReferralObservation <br /> Local 1 Cou <br /> If Referral,choose referral type(Fill one) <br /> Identifier: Sup, Jipe� u 1 n_ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> LBusiness or Facility, ame <br /> r Inspected By. Inspector <br /> Physical Ad ss <br /> LL L b. I _ L- <br /> Street I <br /> _ C Inspection Date ! j� -Q i �� i V I g- <br /> CitV State ZIP Codd Time In - _ Time Out <br /> Business Re Title i <br /> Rep % AM <br /> 0PM I ' L_�I S <br /> I OPM <br /> _ - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) . (Fill one only) (Fill all that apply) (Fill all that apply) _(Fill all that apply) <br /> t ® Active S Passenger O.Generator 0 Outdoor <br /> I oClosed 0 Altered <br /> GPS Latitude ,I I ® Hauler 0.Indoor <br /> 0 Inactive 0 Truck <br /> i <br /> Longitude 0 Planned OTR 0 End-Use ®Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair .0 Trucking Fleet . 0 Government 0 Retreader 0 Dismantler -0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other L i <br /> Part B - Inspection of Waste.Tire Dealer,-Generator, Hauler and End-Use facility .ENFORCEMENT STATUS ; <br /> aV Ate: HAULINGAND MANIFEST�REQUIREMENTS ' r � � r � <br /> i.•�* <br /> .� NOtiC00f VIOI,atlOn�a � EXtenSlOn <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �;� + rix A% <br /> O O � :� ��,� m <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. " ; <br /> 0 0 § 9 Compl(ance Deadline, <br /> 0 0 PRC§42956-.Registration/Decal in Vehicle 's"�� � '��� <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> p <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB ` <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (RequireC%r NOV orE)CT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire.End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire-Dealers.or Waste Tire Generators <br /> 10 In Compliances No Violations <br /> 0 0 <br /> Other: <br /> Comments <br /> ccs—c =C,unwn-- — <br /> Inspection Form Included: 0 C�/-�/ Q )t� <br /> Comments Included: 0 ���—/-(1[�7 - - — _U`31-/-�- <br /> Business Re 's Si nature Insa is 1 nature. Phone Number <br /> p g Phone Number,/ p g P o <br /> INSTRUCTIONS ON BACK Cor ect: Incorrect: �( � �I.X AIM P L � Z Z 3 s2os1 <br /> ■ White Cop OW Yellow Copy.Operator Pink Copy:LEA ■ <br />