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Waste Tire Sr._ ey & Inspection Repor , Inspection Report Number <br /> Stale of Callfornia <br /> CIWMB181(New 04f04) Survey Form - Page 1 1 6 ` 10 /j�L 5 t 7 5 //�L <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; / [7 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 10 CHP 0 CIWM8 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Il �!� // Inspected By Inspector <br /> Physical A�Qs l90lKCK � <br /> / / �6151m�o4f� <br /> j Inspection Date G 3 I ., / I Q <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> !* QPM QPM <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 /> f f 0 Active d Passenger • Generator 0 Outdoor <br /> D 0 Closer) 0 Altered <br /> GPS Latitude 0 HaulerIndoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> S` A j HAULING AND MAN(FEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Gompllanee Deadline <br /> 0 I 0 PRC§42956-Reg)stration/Decal in Vehicle <br /> 0 i 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 1 0 14 CCR§ 18459.1 (a)(b)(c) -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Fonts and Tire Trip Logs within 90 days (Required for NOV or E?C7) <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2- Manifest System Requirements for Registered Waste Tire Haulers Q RQferra.d 1 eIwMB 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 /> In CAmpllancQ No Violatlone <br /> 0 i 0 Other: § - <br /> Comments p / t --�' �+ <br /> 44W-aeo � i'n e, Sur -- Tis -47G, /he PYo�n. -v� -- / 'r - — <br /> ��'u'v�. <br /> M's eo 70-t- <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> B Iness Rep's Signature Phone ber ignature Phone Number <br /> ll ll 62081 <br /> INSTRUCTIONS ON BACK 'Correct: 1ncrr�icta /, � '_?�- ._.-1 _ .( .� Mer <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />