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=6, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Sate ofCalifornia Survey Form - Page 1 1 5 1 0 1 3 8 9 8 <br /> CIWMB 181(New 04104) <br /> California IntegratedgratedWaste 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: q 6 � -7 D / <br /> / � � / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /\f // If Referral,choose referral type(Fill one) <br /> Identifier: JAIL C/,,aj"'�f C ?Llsz Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - 1 / ,����,/yr ✓,A <br /> y 3 se" /xS <br /> Inspection Date 0 / 2_9 / (� <br /> Time In Time Out <br /> Business Rep Title Q AM <br /> O Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ .Active Q Passenger QGenerator <br /> Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler QIndoor <br /> O Q inactive Q Truck <br /> Longitude - Q Planned Q OTRjo End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End-Use Facility 'ENFORCEMENT STATUS <br /> V A: HAULIM <br /> NG AND ACt1(PST REQUIREMENTS Q Notice Of Violation Q Extanston <br /> ... _. j <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date J / m / <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB I �� <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days {Requ(msd for NOV or EX7) <br /> Q' Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers0 Referred!CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance - No Violations <br /> Q Q i Other: § _. <br /> Comments <br /> Aao a � ww'e eeb"' gey .PSE, '".'e <br /> `�i"y tzeoyral Av' 9i"+ F+eta U0_4 <br /> Inspection Form Included:Q q `, <br /> Comments Included:Q <br /> I Business Rep's S nature one Number Inspectors Signature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACKE X A/JIM P L E 1 ?Z 3 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA '® ■ <br /> 0633304.0075 <br />