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spection Report Number <br /> M <br /> . Waste Tire Sur & Inspection Report.- p <br /> • State of California 1 i "- A <br /> i CIWMB 181(New 04/04) Survey Form - Page 1 et <br /> California Integrated Waste Management Board - -'. <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> �. <br /> Deta[Is <br /> Business Profile OREM, I Insection <br /> p <br /> TPID- y , / Inspection Type (Fill one) <br /> Site Suffix. C iEd- q / f) Routine 0 Re-inspection 0 Referral 0 Observation <br /> a___.— <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: 6 t.(( L �(j(1�.,1 ,(y �y .(� -.( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Namev (` Inspected By Inspector <br /> Physical Address - L ._ <br /> Street0 <br /> p <br /> Ins ection Date 1 1 <br /> J J /l f' ML <br /> C hly -� State Zip Code Time In _ Time Out <br /> Business Rep Title O AM0 PM AM <br /> Bus qqAAAx <br /> . Ir., .�_ • �� � _ �_ 0 PM <br /> AA — Operational Status Tire Type Business Role Storage Type <br /> rr <br /> (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> �tire Gaunt�1Nhr�lel " <br /> •y,)>° _ ""� Active 0 Passenger 3 Generator 0 Outdoor <br /> (� 0 Closed 0 Altered <br /> GPS Latitude EI] <br /> , �14 �__� Q Hauler 0 Indoor <br /> _..q0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> r <br /> 0 New Tire Dealer 0 Auto Repair ® 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 /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <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 (Required for NOV or EXT) <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/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 In Compliance No Violations <br /> 0 0 Other: § - - - - <br /> Comments <br /> LIL— <br /> C <br /> to , <br /> Inspection Form Included: 01 -- - <br /> Comments Included: D - -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _.��W.O. r _ -_.. �B 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X I L,F ( t L; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />